Intratracheal pressure: a more accurate reflection of pulmonary airway pressure in pediatric patients with respiratory failure.

OBJECTIVES

Peak inflation pressure (PIP) on many ventilators (P(vent)), measured distal to the exhalation limb or Y-piece of the breathing circuit, is assumed as the pressure applied to the airways and lungs. However, in vitro studies show P(vent) data are spurious. There are no studies evaluating the accuracy of P(vent) data for pediatric patients with acute respiratory failure. We hypothesized that intratracheal airway pressure (P(T)) is more accurate than P(vent) and that by using P(vent), abnormally increased imposed resistive work of breathing (WOBi) may go undetected.

DESIGN

Prospective and descriptive study.

SETTING

A pediatric intensive care unit at a university hospital.

PATIENTS: Twenty-one pediatric patients with respiratory failure requiring mechanical ventilation.

INTERVENTIONS: All patients were intubated with a commercially available endotracheal tube (ETT) with a pressure measuring the lumen opening at the distal end used for measuring P(T). Pressure/flow sensors positioned between the ETT and Y-piece measured tidal volume (V(T)) and flow rate. P(vent) data were recorded as displayed on the ventilator. WOBi was measured by integrating P(T) and V(T) data.

RESULTS

PIP at P(vent) and P(T) were 26 +/- 8 cm H(2)O and 19 +/- 7 cm H(2)O, respectively (p < .05). P(T) measurements averaged 27% less than P(vent). The relationship between P(vent)-P(T) (pressure drop across the breathing circuit and ETT) and flow rate during spontaneous inhalation was highly correlated (r = .80, p < .002), indicating the greater the flow rate, the greater the pressure drop and WOBi. WOBi, ranging from 0.04-1.5 J/L, was measured in 52% of the patients.

CONCLUSIONS

P(vent) significantly overestimates PIP. Moreover, P(vent) data does not allow for recognition of increased WOBi for many patients. Clinicians need to be aware of the limitations of P(vent) data and consider using ETTs that allow measurement of P(T), a more accurate reflection of pulmonary airway pressure.