Prevention of endotracheal suctioning-induced alveolar derecruitment in acute lung injury.

We studied endotracheal suctioning-induced alveolar derecruitment and its prevention in nine patients with acute lung injury. Changes in end-expiratory lung volume measured by inductive plethysmography, positive end-expiratory pressure-induced alveolar recruitment assessed by pressure-volume curves, oxygen saturation, and respiratory mechanics were recorded. Suctioning was performed after disconnection from the ventilator, through the swivel adapter of the catheter mount, with a closed system, and with the two latter techniques while performing recruitment maneuvers during suctioning (40 cm H2O pressure-supported breaths). End-expiratory lung volume after disconnection fell more than with all other techniques (-1,466 +/- 586, -733 +/- 406, -531 +/- 228, -168 +/- 176, and -284 +/- 317 ml after disconnection, through the swivel adapter, with the closed system, and with the two latter techniques with pressure-supported breaths, respectively, p < 0.001), and was not fully recovered 1 minute after suctioning. Recruitment decreased after disconnection and using the swivel adapter (-104 +/- 31 and -63 +/- 25 ml, respectively), was unchanged with the closed system (-1 +/- 10 ml), and increased when performing recruitment maneuvers during suctioning (71 +/- 37 and 60 +/- 30 ml) (p < 0.001). Changes in alveolar recruitment correlated with changes in lung volume (rho = 0.88, p < 0.001) and compliance (rho = 0.9, p < 0.001). Oxygenation paralleled lung volume changes. Suctioning-induced lung derecruitment in acute lung injury can be prevented by performing recruitment maneuvers during suctioning and minimized by avoiding disconnection.

[1]  M. Lamy,et al.  The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. , 1994, American journal of respiratory and critical care medicine.

[2]  P. Grenier,et al.  A computed tomographic scan assessment of endotracheal suctioning-induced bronchoconstriction in ventilated sheep. , 2000, American journal of respiratory and critical care medicine.

[3]  A Lymberis,et al.  Expiratory flow limitation and intrinsic positive end-expiratory pressure at zero positive end-expiratory pressure in patients with adult respiratory distress syndrome. , 2000, American journal of respiratory and critical care medicine.

[4]  B Jonson,et al.  Influence of tidal volume on alveolar recruitment. Respective role of PEEP and a recruitment maneuver. , 2001, American journal of respiratory and critical care medicine.

[5]  B. M. Kuzenski Effect of negative pressure on tracheobronchial trauma. , 1978, Nursing research.

[6]  J. Katz,et al.  Time Course and Mechanisms of Lung‐volume Increase with PEEP in Acute Pulmonary Failure , 1981, Anesthesiology.

[7]  D. Hess,et al.  An evaluation of the effectiveness of secretion removal with the Ballard closed-circuit suction catheter , 1991 .

[8]  C. Carvalho,et al.  Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. , 1998, The New England journal of medicine.

[9]  Steven B. Johnson,et al.  Closed versus open endotracheal suctioning: Costs and physiologic consequences , 1994, Critical care medicine.

[10]  F. Jardin,et al.  Pressure-volume curves in acute respiratory distress syndrome: clinical demonstration of the influence of expiratory flow limitation on the initial slope. , 2002, American journal of respiratory and critical care medicine.

[11]  L. Brochard,et al.  Constant-flow Insufflation Prevents Arterial Oxygen Desaturation during Endotracheal Suctioning , 1991 .

[12]  A. Armaganidis,et al.  Causes of error of respiratory pressure-volume curves in paralyzed subjects. , 1988, Journal of applied physiology.

[13]  D. Pierson,et al.  Prevention of arterial oxygen desaturation during closed-airway endotracheal suction , 1984 .

[14]  F. Lemaire,et al.  Accuracy of pulse oximetry in the intensive care unit , 2001, Intensive Care Medicine.

[15]  M. Sackner,et al.  Effect of airway diameter, suction catheters, and the bronchofiberscope on airflow in endotracheal and tracheostomy tubes. , 1976, Heart & lung : the journal of critical care.

[16]  P. Pelosi,et al.  Recruitment and derecruitment during acute respiratory failure: a clinical study. , 2001, American journal of respiratory and critical care medicine.

[17]  Peter M. Suter,et al.  Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial. , 1999, JAMA.

[18]  A S Slutsky,et al.  Mechanical ventilation affects local and systemic cytokines in an animal model of acute respiratory distress syndrome. , 1999, American journal of respiratory and critical care medicine.

[19]  L Puybasset,et al.  Computed tomography assessment of positive end-expiratory pressure-induced alveolar recruitment in patients with acute respiratory distress syndrome. , 2001, American journal of respiratory and critical care medicine.

[20]  C. Roussos,et al.  Effects of positive end-expiratory pressure on gas exchange and expiratory flow limitation in adult respiratory distress syndrome* , 2002, Critical care medicine.

[21]  A. Pesenti,et al.  Closed system endotracheal suctioning maintains lung volume during volume-controlled mechanical ventilation , 2001, Intensive Care Medicine.

[22]  B. Jonson,et al.  Surfactant dysfunction makes lungs vulnerable to repetitive collapse and reexpansion. , 1997, American journal of respiratory and critical care medicine.

[23]  Taggart Ja,et al.  Airway pressures during closed system suctioning. , 1988 .

[24]  Arthur S Slutsky,et al.  Tidal ventilation at low airway pressures can augment lung injury. , 1994, American journal of respiratory and critical care medicine.

[25]  G. Carlon,et al.  Evaluation of a closed-tracheal suction system. , 1987, Critical care medicine.

[26]  M. L. Noll,et al.  Closed tracheal suction systems: effectiveness and nursing implications. , 1990, AACN clinical issues in critical care nursing.

[27]  B Jonson,et al.  Alveolar derecruitment at decremental positive end-expiratory pressure levels in acute lung injury: comparison with the lower inflection point, oxygenation, and compliance. , 2001, American journal of respiratory and critical care medicine.

[28]  V. Ranieri,et al.  Volume-pressure curve of the respiratory system predicts effects of PEEP in ARDS: "occlusion" versus "constant flow" technique. , 1994, American journal of respiratory and critical care medicine.

[29]  L Puybasset,et al.  A scanographic assessment of pulmonary morphology in acute lung injury. Significance of the lower inflection point detected on the lung pressure-volume curve. , 1999, American journal of respiratory and critical care medicine.

[30]  D. Dreyfuss,et al.  Pressure-volume curves: searching for the grail or laying patients with adult respiratory distress syndrome on procrustes' bed? , 2001, American journal of respiratory and critical care medicine.

[31]  B Jonson,et al.  Pressure-volume curves and compliance in acute lung injury: evidence of recruitment above the lower inflection point. , 1999, American journal of respiratory and critical care medicine.

[32]  L. Brochard,et al.  A Single Computer-Controlled Mechanical Insufflation Allows Determination of the Pressure-Volume Relationship of the Respiratory System , 2004, Journal of Clinical Monitoring and Computing.

[33]  V. Ranieri,et al.  Cardiorespiratory Effects of Positive End-expiratory Pressure during Progressive Tidal Volume Reduction (Permissive Hypercapnia) in Patients with Acute Respiratory Distress Syndrome , 1995, Anesthesiology.

[34]  J. Civetta,et al.  The effect of short‐term discontinuation of high‐level PEEP in patients with acute respiratory failure , 1979, Critical Care Medicine.

[35]  D. Hudgel,et al.  Accuracy of tidal volume, lung volume, and flow measurements by inductance vest in COPD patients. , 1984, Journal of applied physiology: respiratory, environmental and exercise physiology.

[36]  J. Mead,et al.  Stress distribution in lungs: a model of pulmonary elasticity. , 1970, Journal of applied physiology.

[37]  V. Ranieri,et al.  Effects of positive end-expiratory pressure on alveolar recruitment and gas exchange in patients with the adult respiratory distress syndrome. , 1991, The American review of respiratory disease.