Pratik Sinha, Nicholas J Fauvel, Pradeep Singh, Neil Soni Critical Care 2013, 17:R34 (27 February 2013)
Introduction: Due to complexities in its measurement, adequacy of ventilation is seldom used to categorize disease severity and guide ventilatory strategies. Ventilatory ratio (VR) is a novel index to monitor ventilatory adequacy at the bedside. VR = (expired measured minute ventilation [VEmeasured] x measured arterial partial pressure of carbon dioxide [PaCO2measured])/(expired predicted minute ventilation [VEpredicted] x ideal arterial partial pressure of carbon dioxide [PaCO2ideal]). VEpredicted is 100 mL.Kg-1.min-1 and PaCO2ideal is 5 kPa. Physiological analysis shows that VR is influenced by dead space (VD/VT) and CO2 production (VCO2). Two studies were conducted to explore the physiological properties of VR and assess its use in clinical practice.

Methods: Both studies were conducted in adult mechanically ventilated intensive care unit (ICU) patients. In Study 1 volumetric capnography was used to estimate daily VD/VT and measure VCO2 in 48 patients. Simultaneously ventilatory ratio was calculated using arterial blood gas measurements alongside respiratory and ventilatory variables. This data was used to explore the physiological properties of VR. In Study 2, 224 ventilated patients had daily VR and other respiratory variables, baseline characteristics, and outcome recorded. The database was used to examine the prognostic value of VR.

Results: Study 1 showed that there was significant positive correlation between VR and VD/VT (modified r=0.71) and VCO2 (0.14). The correlation between VR and VD/VT was stronger in mandatory ventilation compared to spontaneous ventilation. Linear regression analysis showed that VD/VT had a greater influence on VR than VCO2 (standardized regression coefficient 1/1-VD/VT: 0.78, VCO2: 0.44). Study 2 showed that VR was significantly higher in non-survivors compared to survivors (1.55 vs 1.32; p<0.01). Univariate logistic regression showed that higher VR was associated with mortality (odds ratio (OR) 2.3, p<0.01), this remained the case after adjusting for confounding variables (OR 2.34, p=0.04).

Conclusions: VR is an easy to calculate bedside index of ventilatory adequacy and appears to yield clinically useful information.

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