Typical patterns of expiratory flow and carbon dioxide in mechanically ventilated patients with spontaneous breathing

Incomplete expiration of tidal volume can lead to dynamic hyperinflation and auto-PEEP. Methods are available for assessing these, but are not appropriate for patients with respiratory muscle activity, as occurs in pressure support. Information may exist in expiratory flow and carbon dioxide measurements, which, when taken together, may help characterize dynamic hyperinflation. This paper postulates such patterns and investigates whether these can be seen systematically in data. Two variables are proposed summarizing the number of incomplete expirations quantified as a lack of return to zero flow in expiration (IncExp), and the end tidal CO₂ variability (varETCO₂), over 20 breaths. Using these variables, three patterns of ventilation are postulated: (a) few incomplete expirations (IncExp < 2) and small varETCO₂; (b) a variable number of incomplete expirations (2 ≤ IncExp ≤ 18) and large varETCO₂; and (c) a large number of incomplete expirations (IncExp > 18) and small varETCO₂. IncExp and varETCO₂ were calculated from data describing respiratory flow and CO₂ signals in 11 patients mechanically ventilated at 5 levels of pressure support. Data analysis showed that the three patterns presented systematically in the data, with periods of IncExp < 2 or IncExp > 18 having significantly lower variability in end-tidal CO₂ than periods with 2 ≤ IncExp ≤ 18 (p < 0.05). It was also shown that sudden change in IncExp from either IncExp < 2 or IncExp > 18 to 2 ≤ IncExp ≤ 18 results in significant, rapid, change in the variability of end-tidal CO₂ p < 0.05. This study illustrates that systematic patterns of expiratory flow and end-tidal CO₂ are present in patients in supported mechanical ventilation, and that changes between these patterns can be identified. Further studies are required to see if these patterns characterize dynamic hyperinflation. If so, then their combination may provide a useful addition to understanding the patient at the bedside.