Volume guarantee ventilation, interrupted expiration, and expiratory braking

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Abstract
Background: In volume guarantee ventilation with the Dräger Babylog 8000 ventilator, inspiratory and expiratory flows are monitored and the expiratory tidal volume calculated following each inflation. The pressure for the next inflation is modified to ensure the expired tidal volume is close to the set value. Aim: To investigate interrupted expiration observed during volume guarantee ventilation of spontaneously breathing, ventilated infants. Methods: Spontaneously breathing infants, ventilated with volume guarantee, had recordings of gas flow, ventilator pressures, tidal volume waveforms, oximetry, heart rate, and transcutaneous oxygen and carbon dioxide during 10 minute recordings. Results: A total of 6540 inflations were analysed from 10 infants; 62% were triggered. Two different patterns were found: (1) Normal volume guarantee pattern with 97% of triggered and 91% untriggered inflations. It had a normal expiratory curve and a mean expired tidal volume within 3% of the set volume, but a large variation due to the babies’ breathing. (2) A pattern of interrupted expiratory flow after ∼3% of inflations due to a small inspiration (∼1.3 ml/kg) during expiration. This led the ventilator to calculate an inappropriate total expired tidal volume for that inflation and an increase in the pressure for the next inflation. Conclusions: After about 3% of inflations, with volume guarantee ventilation, interruption of the expiration causes an increased pressure for the next inflation of ∼4.9 cm H2O, compared with normal volume guarantee inflation. The interrupted expiration is most likely to be due to diaphragmatic braking.