Optimization of respiratory muscle relaxation during mechanical ventilation.

The authors calculated the active work of inspiration (Wp) and the inspiratory muscle pressure-time product (integral of Pmus.dt) in seven patients undergoing mechanical ventilation (MV). This was done by comparing the areas under the inflation pressure-volume and inflation pressure-time curves generated when the patient was contributing to the work of ventilation with those following sedation, when inspiratory muscle activity was absent (defined as absence of diaphragmatic EMG activity and of palpable accessory muscle contraction). Inspiratory muscle inactivity could be predicted by the observation of a smooth rise in inflation pressure that was highly reproducible from breath to breath. Relaxation was present without sedation during MV in the control mode with inspiratory flow rates above 65 1/min. In the assist mode (AMV), both Wp and integral of Pmus.dt were significantly (P less than 0.05) greater than in the control (CMV) mode. Reducing trigger sensitivity during AMV further increased Wp and integral of Pmus.dt (P less than 0.05). During AMV and CMV Wp and integral of Pmus.dt decreased with increasing rate of inspiratory flow delivered by the ventilator. With AMV at low trigger sensitivity and low flow rates, Wp approached 65% of the total inspiratory work. The authors conclude that inspiratory muscle activity can be substantial during MV, particularly during AMV at low trigger sensitivity and flow. Monitoring of inflation pressure is a simple means of determining the degree of inspiratory muscle rest during MV.