Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca...
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![Page 1: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/1.jpg)
Measuring end-expiratory lung volume
Giacomo Bellani, M.D., Ph.D.University of Milano-Bicocca
Monza, [email protected]
![Page 2: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/2.jpg)
Conflicts of interest
Personal:• Lecturing fees from GE
Institutional, research grants from:• Draeger• Maquet• Chiesi Farmaceutici
![Page 3: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/3.jpg)
Which «lung volume» ?
Functional Residual Capacity (FRC)Functional Residual Capacity (FRC)Volume of gas in the lung at the end of a physiologic Volume of gas in the lung at the end of a physiologic
expiration expiration Relaxation volume of respiratory systemRelaxation volume of respiratory system
End Expiratory Lung Volume (EELV)End Expiratory Lung Volume (EELV)Volume of gas in the lung at end expiration during Volume of gas in the lung at end expiration during mechanical ventilation with PEEPmechanical ventilation with PEEP
EELV @ 0 cmH2O= FRC
![Page 4: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/4.jpg)
• How do we measure End-expiratory lung volume?
• Why should we measure end-expiratory lung volume?
![Page 5: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/5.jpg)
TechniquesCT scan
• Precise quantitative assessment• Radiological exposure+patient transfer
Closed circuit• Need for a dedicated tracer+closed system• No need for «fast» response concentration
measurements - offline measurementOpen circuit muti-breath washin/washout
• Potentially no need for a gas tracer• Fast response measurement, synchrony with tidal
ventilation
![Page 6: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/6.jpg)
TechniquesCT scan
• Precise quantitative assessment• Radiological exposure+patient transfer
Closed circuit• Need for a dedicated tracer+closed system• No need for «fast» response concentration
measurements - offline measurementOpen circuit muti-breath washin/washout
• Potentially no need for a gas tracer• Fast response measurement, synchrony with tidal
ventilation
![Page 7: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/7.jpg)
Closed Dilution Technique
VVff = V = Vii + EELV + EELV
Mass conservation
CiCiViVi
FRC ?FRC ?
CfCfVfVf
ViViCfCfCiCi
ViViEELVEELV -=
VVii* C* Cii = V = Vff* C* Cff
![Page 8: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/8.jpg)
![Page 9: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/9.jpg)
TechniquesCT scan
• Precise quantitative assessment• Radiological exposure+patient transfer
Closed circuit• Need for a dedicated tracer+closed system• No need for «fast» response concentration
measurements - offline measurementOpen circuit muti-breath washin/washout
• Potentially no need for a gas tracer• Fast response measurement, synchrony with tidal
ventilation
![Page 10: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/10.jpg)
70 %
30 %O2
N2
50 %
50 %
FiN2=70%
Vt
FeN2
600 ml
1400 ml
1000 ml
1000 ml ml.
ml
..
Nml2000
20
400
5070
400 2
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Multibreath nitrogen washout
Wrigge H et al Intensive Care Med 1998; 24: 487
Off-line correction of viscosity effect on sidestream delay time and pneumothacografic measurments
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Derives N2 concentration from: 100%- [CO2]- [CO2]
Uses end-tidal concentration (no need for synchronization)
![Page 13: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/13.jpg)
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What about Pressure Support ?
0
1000
2000
3000
4000
0 1000 2000 3000 4000
EELV by He dilution (ml)
EE
LV
by
GE
En
gst
rom
(m
l)Volume Control
R2 = 0.8353
Pressure Support
Using a 20% variation in FiO2:
Bellani G, unpublished
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FRC INview (Engstrom carestation)
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![Page 17: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/17.jpg)
![Page 18: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/18.jpg)
• How do we measure End-expiratory lung volume?
• Why should we measure end-expiratory lung volume?
![Page 19: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/19.jpg)
EELV is profoundly reduced in ARDS• Estimate of alveolar
recruitment• Determinant of VILI
Why should we measure end-expiratory lung volume?
![Page 20: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/20.jpg)
EELV is profoundly reduced in ARDS
• Estimate of alveolar recruitment
• Determinant of VILI
Why should we measure end-expiratory lung volume?
![Page 21: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/21.jpg)
Alveolar recruitment by P-V curve
Maggiore S. et al, Am J Resp Crit Care Med, 2001
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Effect of recruitment on FRC (0 cmH2O)
![Page 23: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/23.jpg)
Patroniti N et al., CCM 2010
![Page 24: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/24.jpg)
A simplified approachAssessing alveolar recruitment by EELV
PEEP = 0
Compliance=30 ml/cmH2OEELV= 1000 ml
PEEP=10
Expected EELV increase: 30 * 10= 300 ml
No recruitmentEELV= 1300 ml
RecruitmentEELV = 1600 ml
![Page 25: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/25.jpg)
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
4 14
PEEP (cmH2O)
EE
LV
(l)
0
5
10
15
20
25
30
35
Crs
(m
l/cm
H2O
)
6 8 10 12
1350 ml
Crs 29 expected EELV increase 174 ml
1524 l
1950 l
true EELV increase 600 ml
∆EELV / PEEP change = 600 / 6 = 100 ml/cmH2O
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EELV is profoundly reduced in ARDS• Estimate of alveolar
recruitment• Determinant of VILI
Why should we measure end-expiratory lung volume?
![Page 29: Measuring end-expiratory lung volume Giacomo Bellani, M.D., Ph.D. University of Milano-Bicocca Monza, Italy giacomo.bellani1@unimib.it.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ef55503460f94c08f53/html5/thumbnails/29.jpg)
EELV
VE (L/min)
RATIO
NORMAL
ARDS
2500 < 7 < 2.8
1000 > 15 > 15
SPECIFIC HYPERVENTILATION
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Vt/F
RC
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End-expiration End-inspiration PETEELVnormally-aerated
Vtnormally-aerated
Kinormally-aerated
High activity
Low activity
- 1000
100
-500
Regional distension and inflammation
Bellani G et al., Am J Resp Crit Care Med, 2011
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The role of tidal volume/EELV
Bellani G et al., Am J Resp Crit Care Med, 2011
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Conclusions:o Measurement of end-expiratory lung volume is
now available:RESEARCH TOOL → CLINICAL TOOL
o Useful in estimating lung recruitmentoCan it help in setting PEEP? Yeso Is it being used to set PEEP? Don’t know
o Possible role in adjusting tidal volume?
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