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Analysis of ventilatory ratio as a novel method to monitor ventilatory adequacy at the bedside

Authors:	Pratik Sinha Nicholas J Fauvel Pradeep Singh Neil Soni

Affiliation:	1.Magill Department of Anaesthesia, Intensive Care Medicine and Pain Management, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK;2.Department of Mathematics, Southeast Missouri State University, One University Plaza, Cape Girardeau, MO 63701, USA

Abstract:	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. $VR = ({\dot{V}}_{E m e a s u r e d} \times P a_{C O_{2 m e a s u r e d}}) / ({\dot{V}}_{E p r e d i c t e d} \times P a_{C O_{2 i d e a l}})$ . ${\dot{V}}_{E p r e d i c t e d}$ is 100 mL.Kg^-1.min^-1and Pa_{CO_{2 ideal}} is 5 kPa. Physiological analysis shows that VR is influenced by dead space (V_D/V_T) and CO2 production $(\dot{V} C O_{2})$ . 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 ICU patients. In Study 1, volumetric capnography was used to estimate daily V_D/V_Tand measure $\dot{V} C O_{2}$ 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 $\dot{V} C O_{2}$ (r = 0.14). The correlation between VR and V_D/V_Twas stronger in mandatory ventilation compared to spontaneous ventilation. Linear regression analysis showed that V_D/V_Thad a greater influence on VR than $\dot{V} C O_{2}$ (standardized regression coefficient 1/1-V_D/V_T: 0.78, $\dot{V} C O_{2}$ : 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 (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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