Am. J. Respir. Crit. Care Med., Volume 161, Number 2, February 2000, 432-439

An Objective Analysis of the Pressure-Volume Curve in the Acute Respiratory Distress Syndrome

R. SCOTT HARRIS, DEAN R. HESS, and JOSÉ G. VENEGAS

Pulmonary and Critical Care Unit, Department of Medicine, and Department of Anesthesia, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

To assess the interobserver and intraobserver variability in the clinical evaluation of the quasi-static pressure-volume (P-V) curve, we analyzed 24 sets of inflation and deflation P-V curves obtained from patients with ARDS. We used a recently described sigmoidal equation to curve-fit the P-V data sets and objectively define the point of maximum compliance increase of the inflation limb (P_mci,i) and the true inflection point of the deflation limb (P_inf,d). These points were compared with graphic determinations of lower Pflex by seven clinicians. The graphic and curve-fitting methods were also compared for their ability to reproduce the same parameter value in data sets with reduced number of data points. The sigmoidal equation fit the P-V data with great accuracy (R² = 0.9992). The average of Pflex determinations was found to be correlated with P_mci,i (R = 0.89) and P_inf,d (R = 0.76). Individual determinations of Pflex were less correlated with the corresponding objective parameters (R = 0.67 and 0.62, respectively). Pflex + 2 cm H₂O was a more accurate estimator of P_inf,d (2 SD = ±6.05 cm H₂O) than Pflex was of P_mci,i (2 SD = ±8.02 cm H₂O). There was significant interobserver variability in Pflex, with a maximum difference of 11 cm H₂O for the same patient (SD = 1.9 cm H₂O). Clinicians had difficulty reproducing Pflex in smaller data sets with differences as great as 17 cm H₂O (SD = 2.8 cm H₂O). In contrast, the curve-fitting method reproduced P_mci,i with great accuracy in reduced data sets (maximum difference of 1.5 cm H₂O and SD = 0.3 cm H₂O). We conclude that Pflex rarely coincided with the point of maximum compliance increase defined by a sigmoid curve-fit with large differences in Pflex seen both among and within observers. Calculating objective parameters such as P_mci,i or P_inf,d from curve-fitted P-V data can minimize this large variability. Harris RS, Hess DR, Venegas JG. An objective analysis of the pressure-volume curve in the acute respiratory distress syndrome.

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