Increased initial flow rate reduces inspiratory work of breathing during pressure support ventilation in patients with exacerbation of chronic obstructive pulmonary disease

Objective: To investigate whether the level of initial flow rate alters the work of breathing in chronic obstructive pulmonary disease (COPD) patients ventilated in pressure support ventilation (PSV). Design. Prospective study. Settings. Medical ICU in University hospital. Patients: Eleven intubated COPD patients. Methods: We modulated the initial flow rate in order to achieve seven different sequences. In each sequence, the plateau pressure was reached within a predetermined time: 0.1, 0.25, 0.50, 0.75, 1, 1.25 or 1.50 s. The more rapidly the pressure plateau was achieved, the higher was the initial flow rate. In each patient, the pressure support level was an invariable parameter. The order of the seven sequences for each patient was determined randomly. Measurements and results: Ten minutes after application of each initial flow rate, we measured the following parameters: inspiratory work of breathing, electromyogram (EMG) of the diaphragm (EMGdi), breathing pattern, and intrinsic positive end-expiratory pressure (PEEPi). Comparison between the means for each sequence and each variable measured was performed by two-way analysis of variance with internal comparisons between sequences by Duncan's test. The reduction of the initial flow rate induced a progressive increase in the values of the work of breathing, EMGdi, and mouth occlusion pressure (P 0.1). In contrast, the reduction of the initial flow rate did not induce any significant change in tidal volume, respiratory frequency or PEEPi. Conclusion: As the objective of PSV is to reduce the work of breathing, it seems logical to use the highest initial flow rate to induce the lowest possible work of breathing in COPD ventilated patients.