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Effective ventilation at conventional rates with tidal volume below instrumental dead space: a bench study
  1. Martin Keszler1,
  2. Maria Brugada Montaner2,
  3. Kabir Abubakar3
  1. 1Department of Pediatrics, Brown University, Women and Infants Hospital, Providence, Rhode Island, USA
  2. 2Department of Neonatology, University Hospital Materno-Infantil La Fe, Valencia, Spain
  3. 3Department of Pediatrics, Georgetown University Hospital, Washington, DC, USA
  1. Correspondence to Martin Keszler, Department of Pediatrics, Warren Alpert Medical School, Brown University, Women and Infants Hospital of Rhode Island, 101 Dudley Street, Providence, RI 02905, USA; Mkeszler{at}


Objective The authors previously showed that 48% of infants <800 g were ventilated with tidal volume (VT) < dead space (DS) using volume guarantee (VG) ventilation. Here, The authors sought to confirm those findings under the rigorous conditions of a bench study.

Design and methods The authors measured the time to wash out CO2 from a 45-ml test lung using end-tidal CO2 monitor (ETCO2). The test lung was filled with 100% CO2, then ventilated using VG at VT ranging from DS+2 ml to DS–1.5 ml. With ventilation, ETCO2 declined exponentially as CO2 was washed out, the rate being proportional to VT – effective instrumental DS. The time from initiation of ventilation to threshold of accurate detection was determined in triplicate.

Results Halving the theoretical ‘alveolar ventilation’ (DS+2 ml to DS+1 ml) only increased the elimination time by 26%, not the 100%, as predicted by conventional physiology. CO2 washout was less efficient, but still occurred even at VT=DS and VT=DS–1.5 ml. Halving the theoretical ‘alveolar ventilation’ by decreasing respiratory rate from 80 to 40 breaths/min only increased elimination time by 35%, not 100%, as predicted by conventional physiology. Twenty minutes of continuous positive airway pressure prior to ventilation did not alter the elimination time, verifying that CO2 did not diffuse or leak out of the test lung. Size of the endotracheal tube (ETT; 2.5, 3.0 and 3.5 mm) flow rate (4, 6 and 10 l/min) and inspiratory time (0.25 vs 0.35 s) did not affect the results.

Conclusions Contrary to conventional physiology, effective CO2 elimination appears to be possible with VT<DS even at conventional rates. With small ETT a spike of fresh gas likely penetrates through the DS, rather than pushing it ahead.

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  • Competing interests Dr M. Keszler has been a consultant to Draeger Medical, the manufacturer of the device used in these studies. The device is not the focus of the study. Dr Keszler does not have any equity interest in the company and no one related to the company has had any input into the design, execution or reporting of the study. No financial or in-kind support was provided by Draeger Medical for this study.

  • Contributors The authors are responsible for the reported research and have participated in the concept, design; analysis and interpretation of data; drafting of the manuscript and have approved the manuscript as submitted.

  • Provenance and peer review Not commissioned; externally peer reviewed.