Detection of endotracheal tube obstruction by analysis of the expiratory flow signal

Objective: Acute obstruction of endotracheal tubes (ETT) increases airway pressure, decreases tidal volume, increases the risk of dynamic :hyperinflation by prolonging the duration of passive expiration, and prevents reliable calculation of tracheal pressure. We propose a computer-assisted method for detecting ETT obstruction during controlled mechanical ventilation. The method only requires measurement of; the expiratory flow. Design: Computer simulation; prospective study in two cases; retrospective study in one case and in seven patients with the adult respiratory distress syndrome (ARDS). Setting: Laboratory of the Section of Experimental Anaesthesiology (University of Freiburg); surgical adult intensive care units in a university hospital (University of Basel) and in a university affiliated hospital (Zentralklinikum Augsburg). Patients: 3 patients with partial ETT or bronchial obstructions and 7 ARDS patients, Measurements and results: Expiratory flow was measured using a pneumotachograph and integrated to obtain expiratory volume. The time-constant of passive expiration (tau(E)) as a function of expired volume [tau(E)(V-E) function] was calculated from the expiratory volume/flow curve. We investigated the tau(E)(V-E) function of data obtained from: (1) computer simulation of mechanically ventilated homogeneous and inhomogeneous lungs intubated with ETTs of different sizes; (2) one patient with an artificial ETT obstruction of 7.5 and 25 % of the cross-sectional area of the ETT (case 1); (3) one patient with ETT obstruction due to secretions (case 2); (4) one patient with acute bronchial constriction (case 3); (5) seven ARDS patients who showed an increase in airway resistance of more than 2 cm H2O.s/l. It was found that an ETT obstruction caused an increase in tau(E) in early expiration (at high flow), whereas tau(E) in late expiration was virtually unchanged. The reason for this is the flow dependency of the increase in ETT resistance produced by ETT obstruction. Unlike ETT obstruction, an increase in pure airway resistance produced an increase in tau(E) throughout expiration. Conclusions: An ETT obstruction can be reliably distinguished from an increase in pure airway resistance by a characteristic pattern change in the tau(E)(V-E) function, which can be detected easily even by an automated pattern recognition system.