Pediatric Simulation of Intrinsic PEEP and Patient-Ventilator Trigger Asynchrony During Mechanical Ventilation

Intrinsic PEEP during mechanical ventilation occurs when there is insufficient time for expiration to functional residual capacity before the next inspiration, resulting in air trapping. Increased expiratory resistance (R_E), too rapid of a patient or ventilator breathing rate, or a longer inspiratory to expiratory time ratio (T_I/T_E) can all be causes of intrinsic PEEP. Intrinsic PEEP can result in increased work of breathing and patient-ventilator asynchrony (PVA) during patient-triggered breaths. We hypothesized that the difference between intrinsic PEEP and ventilator PEEP acts as an inspiratory load resulting in trigger asynchrony that needs to be overcome by increased respiratory muscle pressure (P_mus).

Using a Servo lung model (ASL 5000) and LTV 1200 ventilator in pressure control mode, we developed a passive model demonstrating how elevated R_E increases intrinsic PEEP above ventilator PEEP. We also developed an active model investigating the effects of R_E and intrinsic PEEP on trigger asynchrony (expressed as percentage of patient-initiated breaths that failed to trigger). We then studied if trigger asynchrony could be reduced by increased P_mus.

Intrinsic PEEP increased significantly with increasing R_E (r = 0.97, P = .006). Multivariate logistic regression analysis showed that both R_E and negative P_mus levels affect trigger asynchrony (P < .001).

A passive lung model describes the development of increasing intrinsic PEEP with increasing R_E at a given ventilator breathing rate. An active lung model shows how this can lead to trigger asynchrony since the P_mus needed to trigger a breath is greater with increased R_E, as the inspiratory muscles must overcome intrinsic PEEP. This model will lend itself to the study of intrinsic PEEP engendered by a higher ventilator breathing rate, as well as higher T_I/T_E, and will be useful in ventilator simulation scenarios of PVA. The model also suggests that increasing ventilator PEEP to match intrinsic PEEP can improve trigger asynchrony through a reduction in R_E.