We discuss the principles and application of automatic tube compensation (ATC) on modern ventilators, with its creator Ben Fabry. Dr. Fabry is a professor and chair of biophysics at University of Erlangen-Nuremberg, originally trained as an electrical engineer, who originally developed ATC as part of his PhD program. Find us on Patreon here! Buy your merch here! Takeaway lessons * ATC, originally called “electronic extubation,” is meant to normalize or eliminate the resistance to flow created by the endotracheal tube. Since this resistance is always present, yet is dynamic and varies by flow (and tube size), it creates a continuous confounding variable, making the displayed pressure on the ventilator a measurement not of tracheal pressure, but of another, largely meaningless pressure (the pressure outside the patient). * ATC works by increasing airway pressure during spontaneous inspiration to eliminate the pressure gradient created by the tube at the current flow, and reducing it during expiration to reverse the effect. * While ATC can be used in any mode, it is mostly meant for pressure support or other spontaneous modes. It has no real role in volume control. In pressure control, it has little meaningful impact during inspiration, although it will reduce the airway pressure below the set PEEP during expiration, which may help facilitate expiration. * The original ATC test ventilator could drop pressure below atmospheric pressure during expiration, but this feature is not possible on modern ventilators, so the lowest possible pressure during ATC is zero (probably not quite even, that due to expiratory valve resistance). Some modern vents will not drop pressure during expiration at all. * In principal, actual tracheal pressure could be measured by a separate monitoring lumen. In practice, this is dangerous, as the lumen could be occluded by mucus, so the resistance constant is instead applied mathematically. The modifiers were derived empirically by testing a variety of tubes at different flow rates. * ATC will generally ask for the tube size. Length has some effect but a fairly trivial one, as resistance is mostly influenced by turbulence, which is mainly a product of diameter. Resistance is not a constant, but increases with (roughly) the square of the flow of gas. * A swivel connector on the ETT outlet adds about 1 cm H2O of resistance. An HME adds about 3 cm H2O. * Changes in gas composition at different FiO2 changes resistance trivially, although a mix like Heliox would change it significantly, and would make the internal calculations incorrect. * No fixed single pressure support value can accurately match tube resistance, due to its dynamic nature during and between breaths, even if you were willing to set the sort of pressure needed—which might be 50+ cm H2O in a strongly breathing patient. * The main downside of ATC is that modern ventilators don’t do it very well—they can only vary flow so quickly, so when there are brisk changes in pressure, they fail to match it. They usually can match only about 50% of tube resistance, with the worst at the start of a breath as they lag behind the initial drop in pressure. (You can appreciate this by seeing the airway pressure drop below the set PEEP.) Response is even less in some of the current generation of vents with radial blowers and slower valves * Quality check your ATC by watching the tracheal pressure—the vent will display this ...