• Shazia Mohammad, Nikolaus Gravenstein, Drew Gonsalves, Terrie Vasilopoulos, and Samsun Lampotang.
• From the *Department of Anesthesiology, University of Florida, Gainesville, Florida; †Center for Safety, Simulation & Advanced Learning Technologies, University of Florida, Gainesville, Florida; ‡Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, Florida; and §Clinical & Translational Science Institute Simulation Core, UF Health Shands Experiential Learning Center, University of Florida, Gainesville, Florida.
• Anesth. Analg. 2017 May 1; 124 (5): 150615111506-1511.

BackgroundWe observed that increasing fresh gas flow (FGF) decreased exhaled tidal volume (VT) during pressure control ventilation (PCV). A literature search produced no such description whereby unintended VT changes occur with FGF changes during PCV.MethodsTo model an infant's lungs, 1 lung of a mechanical lung model (Dual Adult TTL 1600; Michigan Instruments, Inc, Grand Rapids, MI) was set at a compliance of 0.0068 L/cm H2O. An Rp50 resistor (27.2 cm H2O/L/s at 15 L/min) simulated normal bronchial resistance. The simulated lung was connected to a pediatric breathing circuit via a 3.5-mm cuffed endotracheal tube. A ventilator with PCV capability (Model 7900; Aestiva, GE Healthcare, Madison, WI) measured exhaled VT, and a flow monitor (NICO; Respironics, Murraysville, PA) measured peak inspiratory flow, positive end-expiratory pressure (PEEP), and peak inspiratory pressure. In PCV mode, exhaled VT displayed by the ventilator at FGF rates of 1, 6, 10, and 15 L/min was manually recorded across multiple ventilator settings. This protocol was repeated for the Avance CS2 anesthesia machine (GE Healthcare).ResultsFor the Aestiva, higher FGF rates in PCV mode decreased exhaled VT. Exhaled VT for FGFs of 1, 6, 10, and 15 L/min were on average 48, 34.9, 16.5, and 10 mL, respectively, at ventilator settings of inspiratory pressure of 10 cm H2O, PEEP of 0 cm H2O, and respiratory rate of 20 breaths/min. This is a decrease by up to 27%, 65.6%, and 79.2% when FGFs of 6, 10, and 15 L/min are compared with a FGF of 1 L/min, respectively. In the GE Avance CS2 at the same ventilator settings, VT for FGF rates of 1, 6, 10, and 15 L/min were on average 46, 43, 40.4, and 39.7 mL, respectively. The FGF effect on VT was not as pronounced with the GE Avance CS2 as with the GE Aestiva.ConclusionsFGF has a significant effect on VT during PCV in the Aestiva bellows ventilator, suggesting caution when changing FGF during PCV in infants. Our hypothesis is that at higher FGF rates, an inadvertent PEEP is developed by the flow resistance of the ventilator relief valve that is not recognized by the ventilator. In turn, less change in pressure is needed to reach the set inspiratory pressure, resulting in lower VT delivery at higher FGF rates. This underappreciated FGF-VT interaction during PCV with a bellows ventilator may be clinically significant in pediatric patients; prospective data collection in patients is needed for further evaluation.

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