Introduction
The evaluation of airway pressure tracings during complete airway occlusion provides
interesting functional data for weaning patients from mechanical ventilation. The
occlusion manoeuvre may be achieved either by maintaining occlusion for a prolonged
period during maximal inspiratory effort (PiMax) or for a shorter time period (200–300
ms). The inspiratory depression of airways pressure, achieved after 100 ms of occlusion,
is generally defined as the occlusion pressure or P0.1 and represents a valid indirect
measurement of the activity of the respiratory centres. P0.1 is a reliable measurement
of the intensity of the stimuli from the neurological centres to the peripheral respiratory
muscles [1,2]. Whitelaw et al elegantly demonstrated the reliability of this measurement
[1] in human healthy volunteers spontaneously breathing at rest and during hypercapnic
challenge. P0.1 can represent a more precise respiratory drive measurement than other
measurements such as tidal volume, respiratory rate, minute ventilation or mean inspiratory
flow (VT/Ti) since it is relatively independent of modification by respiration machines.
The aim of this article is to analyse the technical aspects relating to the acquisition
of occlusion pressures, taking into account the possible bias represented by specific
physiopathologic situations and to define some future uses of P0.1 during weaning
procedures. A complete review of the literature dedicated to P0.1 measurement in different
clinical settings has been recently published [3].
P0.1 measurements
P0.1 can be easily measured at the bedside in both poorly co-operative or mechanically
ventilated patients. When first used in non-intubated patients, this measurement required
the separation of inspiration flow from expiration flow since the system allowed the
selective occlusion of the inspiratory line during exhalation. The subject started
to inhale against a closed inspiratory line, resulting in a depression that was easily
recorded with an air-filled pressure transducer connected to an high speed recorder;
P0.1 could be easily measured and airway pressure changes could be precisely monitored
in the first 100 ms from the onset of inspiration.
The occlusion manoeuvre can be both manually or electrically powered, but must be
noise-free to prevent breathing modification by the patient [1]. The technical requirements
for P0.1 are shown in Table 1. Measurement at 100 ms has been chosen since it was
demonstrated that a normal subject requires at least 150 ms to sense the occlusion
and react against it [1]. The interference due to mouth compliance has, in part, been
considered negligible, although this aspect has not been fully studied. In mechanically-ventilated
patients, P0.1 can be easily measured by inserting a shutter in the ventilator's inspiratory
line, as near as possible to the patient, and recording airway pressure tracing at
the Y piece [4,5,6] (Table 2). However, in patients ventilated using assist-control
or pressure-support ventilation it is possible to use the demand valve system's prolonged
time of response to obtain P0.1 breath-by-breath measurement in conditions of quasi-occlusion.
This measurement was proposed by Taylor et al in 1975 in healthy volunteers connected
to an assist-control circuit. Since the time of response of the demand valve takes
longer than 200–300 ms before the inspiratory valve opens the flow, a phase of inspiration
can be observed against a sort of shutter [7]. The reliability of this non-invasive
measurement has been well confirmed by Fernandez et al [8] in patients mechanically
ventilated in control mode with a sensitive trigger.
We have recently observed a good correlation between the values of P0.1 measured with
the formal occlusion technique and P0.1t (the value computed by observing the airway
pressure change due to the inspiration against a closed demand valve [6]). In that
study all patients had variable levels of intrinsic positive end-expiratory pressure
(PEEPi).
The problem of the reliability of P0.1 measurements in patients with PEEPi is crucial.
In these subjects an important time gradient between the onset of inspiratiory depression
at the alveolar level (ie oesophageal pressure) and the attainment of airways opening
pressure was observed [9]. In other words, the measurement of the inspiratory compensation
of the pressure gradient represented by PEEPi was both work- and time-consuming.
In order to evaluate P0.1 in patients with PEEPi during pressure-support ventilation,
we compared the values of the occlusion pressure obtained from the airway (Paw) and
oesophageal pressure (Poeso) tracings by studying both the depression from the baseline
and the behaviour of the two signals over time [9] (Fig 1). In these conditions we
could confirm the presence of a time delay of 137 ± 88 ms in patients with PEEPi values
below 7 cmH2O. This delay reached 219 ± 130 ms in patients with PEEPi levels over
7 cmH2O. Thus, due to the level of PEEPi, what is considered as P0.1 from airway pressure
tracings is in fact a value in the range of P0.1–0.15 and sometimes P0.2–0.25. However
a close correlation appears when the values of occlusion pressure obtained between
0 and 100 ms and between 100 and 200 ms without formal occlusion are compared to those
values of P0.1 calculated from Paw and Poeso tracings obtained with standard occlusion
techniques.
We may also conclude that P0.1 represents a reliable measure of inspiratory drive
in patients with chronic obstructive pulmonary disease (COPD) with PEEPi and dynamic
hyperinflation, measured both by the formal occlusion technique and by the simplified
measurement proposed by Fernandez et al.
More recently, Brenner et al developed an automatic system to determine P0.1, interfacing
a standard ventilator to a personal computer [10]; with this apparatus they were able
to obtain accurate and non-invasive P0.1 measurements. Nowadays P0.1 can be easily
measured and can be incorporated into the software of ventilators and devices for
monitoring lung mechanics.
Clinical use of P0.1 during weaning
Many clinical and functional tests have been proposed to predict successful weaning
both in patients with acute respiratory failure or acute exacerbation of COPD. These
tests generally include parameters of inspiratory muscle strength (PiMax, vital capacity),
respiratory endurance (maximum voluntary ventilation), respiratory pattern and blood
gases.
However, a majority of COPD patients fulfilling the weaning criteria fail the weaning
trial. Sassoon and colleagues in 1987 [11] compared the traditional parameters with
P0.1 measurement in COPD patients, observing the superiority of this variable in terms
of individual prediction of successful weaning. In this study the authors observed
a precise cut-off of P0.1 at 6 cmH2O. This cut-off identified all the patients that
could be easily weaned. PiMax and vital capacity (VC) were significantly different
between weaned and unweaned patients, but failed to identify individual weaning success;
respiratory pattern analysis was also unpredictive. These data are consistent with
the observation of Murciano et al [5], who found high values of P0.1 in the first
day of exacerbation in a group of COPD patients requiring mechanical ventilation.
These values rapidly returned to normal just before extubation in successfully weaned
patients, but never reached normal values for those individuals requiring reintubation
within 2 or 6 days.
Montgomery and co-workers [12] evaluated the predictability of P0.1 after a hypercapnic
challenge in patients who were assessed as `difficult to be weaned'. The authors started
from the assumption that P0.1 `basal' value could be erroneously low due to the presence
of respiratory muscle fatigue and therefore required a hypercapnic stimulus in order
to evaluate the inspiratory muscle functional reserve. An increase of 10 mmHg in end
tidal CO2 (ETCO2) produced a much higher increase of P0.1 in patients successfully
weaned than in patients who were unsuccessfully weaned [12].
Herrera et al observed high values of P0.1 in a group of active respiratory failure
(ARF) patients [13]. Interestingly the level of P0.1 slowly decreased while the condition
of the patients improved, although minute ventilation and respiratory rate remained
constant. This behaviour was explained by the authors as a result of the presence,
at least in the initial phase, of inspiratory muscle fatigue which limited the peripheral
response to the central drive signals. We recently compared the values of P0.1 to
some currently used weaning parameters [PiMax, VC, respiratory rate (RR), tidal volume
(VT), blood gases, Ti/Ttot] in a group of COPD patients after 30 min pressure support
ventilation, with the aim of detecting early predictors of weaning during pressure
support ventilation (PSV) [6].
Although PiMax, VC and P0.1 were significantly different between successful and failing
patients, only P0.1 could predict successful weaning, with a precise cut-off level
at 4.5 cmH2O. In this study the breathing pattern analysis and mean inspiratory flow
value (VT/Ti) were also unpredictive, probably due to the high level of pressure support
used (20 cmH2O); moreover for each ventilated patient in control mode a clear-cut
correlation was observed between the P0.1 and PEEPi immediately before weaning was
started.
An interesting approach to try to link the measurement of respiratory drive (ventilatory
demand) and functional reserve of the respiratory muscles into a single variable has
been recently proposed by Fernandez et al [14]. These authors suggested the use of
P0.1/PiMax ratio as an index which can theoretically correct values of P0.1 which
are erroneously low due to the presence of respiratory muscle fatigue. The authors
evaluated a group of 50 subjects divided into five subgroups of different respiratory
illness severity [from healthy volunteers to intensive care unit (ICU) patients requiring
full mechanical support]. No correlation between P0.1 and PiMax was observed, but
P0.1/PiMax index increased the reliability of P0.1 in detecting the need for mechanical
support.
Recently, many integrated weaning indexes have been proposed for clinical use, but
few provide comparative data with P0.1. However, there is convincing evidence that
P0.1 represents an interesting variable for the clinical management of patients during
weaning. The possibility of obtaining a valid measurement with a simple, non-invasive
procedure and without interruption of the natural breathing rhythm is awaited with
interest.
Possible innovative applications
From the first report of the use of P0.1 as an indirect way of measuring respiratory
drive [1] in non-intubated patients, this index gained popularity, extending its use
in mechanically ventilated patients, especially during weaning phases. The availability
of software to automatically measure P0.1 using digitised signals from standard ventilators
[10] has contributed to the importance of P0.1 in the analysis of the decisional algorithm
of mechanically ventilated patients.
Further interest for this measurement derives from its correlation with the inspiratory
work of breathing. Olivei and co-workers recently published the first data obtained
with a new method of P0.1 breath-by-breath measurement during PSV [15]. This measurement
was obtained by extrapolating the phase of proto-inspiratory depression from 66 to
100 ms, starting from when the flow signal passes zero. In this way the authors showed
that it was possible to obtain non-invasive continuous P0.1 measurement in patients
connected to machines and to provide a fast response to their inspiratory demand (≤
100 ms). Moreover this study showed a positive correlation between the work of breathing
(WOB) litre of ventilation and the WOB minute (r + 0.86 and 0.90, respectively) [16]
suggesting that P0.1 is reliable not only as a parameter of central drive but also
as the respiratory impedance reflex during assisted inspiration.
More recently Iotti et al validated a system of PSV closedloop control of pressure
support ventilation, based on automatic P0.1 acquisition [17]. These data suggest
possible future applications of continuous automatic P0.1 measurement to correct the
level of respiratory support in patients under assisted ventilation.
Maximum inspiratory pressure (MIP)
MIP or PiMax can be defined as the maximum pressure generated during inspiration against
an occluded airway and this has been demonstrated to be an effective evaluation of
inspiratory muscle strength [18], provided that the lung volume is known at the time
of the measurement. It is, in fact, important to remember that the maximum force generated
by the inspiratory muscles is closely related to the degree of muscular stretching.
MIP is usually measured after a forced expiration to residual volume [19], but some
authors suggest measuring MIP at the point of functional residual capacity (FRC),
in order to mimic spontaneous ventilation. The advantages and disadvantages of the
different methods of measuring MIP are discussed in Table 3. Some differences exist
between authors [20,21] concerning normal MIP values; it is generally accepted, however,
that adult males have values of 115 ± 27 cmH2O, and women have 25% lower values. MIP
tends to decline with age, with a 20% reduction after 70 years. MIP evaluation is
usually simple and reliable in co-operative patients; however, it cannot be easily
measured in critically ill patients who are being mechanically ventilated for acute
respiratory failure. A specific technique for MIP assessment in this situation has
been proposed [22] (Fig 2).
Patients can exhale after each inspiratory effort keeping the expiratory line open
and the inspiratory line occluded for approximately 20 s and progressively achieving
the residual volume and stimulating maximum drive levels. When a `plateau' value is
obtained during two or three consecutive inspirations, this value is considered the
MIP. The method described by Truwit and Marini [23] seems particularly interesting
in patients with reduced central drive levels.
Clinical use of MIP
MIP has been mainly used in a clinical setting to evaluate the respiratory effects
of neuromuscular disease and to assess weaning possibilities. MIP monitoring has been
used during polymyositis and dermatomyositis to evaluate progression toward respiratory
failure [24], or to assess inspiratory muscle strength after unilateral diaphragmatic
paralysis [25]. MIP has also been considered a good `weaning predictor'. In 1973 Sahn
and Lakshminaraian described MIP values of 30 cmH2O as efficient individual predictors
of weaning [26].
However, more recent studies have shown that MIP is much less reliable when used as
the only predictor of weaning, and should always be considered in conjunction with
other variables [6,11].
Finally, MIP values, used in conjunction with P0.1 measurement, have been proposed
as a new index (P0.1/MIP) for increasing the specificity and sensibility of P0.1 to
determine whether patients require artificial ventilatory support or can breathe spontaneously
[14].
In conclusion, MIP is easy to measure, and reflects inspiratory muscle strength. However,
several drawbacks reduce its clinical applicability as a unique variable of reference,
and we recommend its use in conjunction with other variables, such as P0.1 measurement,
respiratory pattern or gas exchange.