How Does Alteration of Airway Resistance Affect Delivered Tidal Volume in Adult Patients Receiving High-Frequency Oscillatory Ventilation?

HOW DOES ALTERATION OF AIRWAY RESISTANCE AFFECT DELIVERED TIDAL VOLUME IN ADULT PATIENTS RECEIVING HIGH-FREQUENCY OSCILLATORY VENTILATION (HFOV)? Concerns exist regarding the ability of HFOV to provide the needed lung protective ventilation for adult patients with ARDS. HFOV is increasingly being used as a lung protecting ventilation mode even if some of its protective attributes may be lost as the airway resistance (Raw) increases or decreases. In fact, in cases of shifting air resistance, HFOV may have caused lung injury. PURPOSE: The purpose of this study was to investigate the effect of airway resistance on tidal volume (Vt) delivered by HFOV to adult patients. Also, the study intended to determine direction for volume change when resistance increases or decreases. METHODS: An in vitro model was used to simulate an adult passive patient with ARDS using a breathing simulator (Active Servo Lung 5000, Ingmar Medical, Pittsburgh, PA, USA). Adjustable resistance and compliance for each lung was used. The resistance levels of 15, 30, 45 (cm H2O/L/sec) were used for upper and lower Raw and CL was fixed at 40 mL/cm H2O. The ventilator (Sensormedics 3100B) was set to MAP = 35 cm H2O, to insp-time of 33%, to bias flow =30 L/min, to delta-P of 80, and to 50% oxygen. Vt was recorded (n=3) for each Raw, and the data was collected on the host computer. Approximately 200-250 breaths of data for each Raw were captured via the ASL software and then converted to Excel for analysis. An average of 80 breathes (following the steady Vt level) was used in each analysis. DATA ANALYSIS: The data analysis was performed with one way ANOVA and with a post hoc Bonferroni test in order to determine the statistical significance of the delivered Vt with each Raw. A probability of (p < 0.05) was accepted as statistically significant. RESULTS: The descriptive statistics of the average delivered Vt with regard to each Raw (15, 30, 45 cm H2O/L/sec) were the number of experiments (n=3), mean Vt (93.52, 89.09, 85.99 mL), and standard deviations (SD) (1.38, 1.11, 1.10) respectively. There was an inverse relationship between tidal volume and airway resistance during HFOV. With all other variables kept constant, higher resistance caused less volume, whereas lower resistance caused more volume. The oneway ANOVA test showed that there were significant differences between the delivered tidal volumes. When the post hoc Bonferroni test was used, the data showed significant differences between airway resistances of 15 cm H2O/L/sec and 30 cm H2O/L/sec and between 15 cm H2O/L/sec and 45 cm H2O/L/sec. In contrast, no significant differences were found between airway resistances of 30 cm H2O/L/sec and 45 cm H2O/L/sec. CONCLUSION: Vt is not constant during HFOV. Airway resistance is one of the determinants of delivered tidal volume in adults with ARDS during HFOV. Airway resistance should be an important factor in ventilator management and in clinical experiments of patients on HFOV. Without a proper Vt measurement device HFOV should not be used as lung protective ventilation for adult patients with ARDS.