Effects of expiratory flow resistance on inspiratory work of breathing

To minimize work of breathing, airway pressure should not fluctuate during spontaneous breathing with continuous positive airway pressure (CPAP). However, flow resistance in the inspiratory limb of the breathing circuit and an inadequate continuous gas flow rate result in airway pressure fluctuation and increased work of breathing. Flow resistance of the expiratory pressure/exhalation valve also directly affects the level of airway pressure during spontaneous inhalation with CPAP (the greater the resistance of the valve, the greater the decrease in airway pressure and work of breathing). We compared this effect with three types of expiratory pressure valves: a threshold resistor with low resistance to flow, an inflatable balloon (mushroom) valve with moderate resistance to flow, and a variable-orifice flow resistor with a high resistance to flow. Work increased up to threefold with the balloon valve and more than tenfold with the flow resistor compared with the threshold resistor. To apply CPAP, expiratory pressure valves with low resistance to flow should be used to minimize fluctuations in airway pressure and, thus, in the work of spontaneous breathing.