Tracheal gas insufflation (TGI) is the continuous or phasic insufflation of fresh gas into the central airways for the purpose of improving the efficiency of alveolar ventilation and/or minimizing the ventilatory pressure requirements. Fresh gas is insufflated near the main carina, usually at flow rates of 2-15 L/min. During expiration, TGI clears the anatomic and apparatus dead space proximal to the catheter tip, thus improving carbon dioxide (CO₂) clearance. Moreover, at high catheter flow rates turbulence generated at the tip of the catheter may enhance distal gas mixing. CO₂ elimination during TGI depends on catheter flow rate, as at higher flow rates a greater portion of the proximal dead space is flushed clear of CO₂. Consequently, as TGI flow is increased, arterial carbon dioxide tension (Paco₂) decreases. Eventually, with increasing catheter flow rate, fresh gas completely flushes the available dead space during expiration and the Paco₂ reaches a plateau. At that point, increasing catheter flow rate decreases Paco₂ much less, probably because of turbulent mixing in the airways distal to the catheter tip. In clinical practice, TGI can be applied either to decrease Paco₂ while maintaining tidal volume constant or to decrease tidal volume while keeping Paco₂ constant. In the former strategy, TGI is used to protect pH, whereas in the latter it is used to minimize the stretch forces acting on the lung parenchyma, to minimize ventilator-associated lung injury.
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