Individualized Positive End-expiratory Pressure and Regional Gas Exchange in Porcine Lung Injury

Background: In acute respiratory failure elevated intraabdominal pressure aggravates lung collapse, tidal recruitment, and ventilation inhomogeneity. Low positive end-expiratory pressure (PEEP) may promote lung collapse and intrapulmonary shunting, whereas high PEEP may increase dead space by inspiratory overdistension. The authors hypothesized that an electrical impedance tomography–guided PEEP approach minimizing tidal recruitment improves regional ventilation and perfusion matching when compared to a table-based low PEEP/no recruitment and an oxygenation-guided high PEEP/full recruitment strategy in a hybrid model of lung injury and elevated intraabdominal pressure. Methods: In 15 pigs with oleic acid–induced lung injury intraabdominal pressure was increased by intraabdominal saline infusion. PEEP was set in randomized order: (1) guided by a PEEP/inspired oxygen fraction table, without recruitment maneuver; (2) minimizing tidal recruitment guided by electrical impedance tomography after a recruitment maneuver; and (3) maximizing oxygenation after a recruitment maneuver. Single photon emission computed tomography was used to analyze regional ventilation, perfusion, and aeration. Primary outcome measures were differences in PEEP levels and regional ventilation/perfusion matching. Results: Resulting PEEP levels were different (mean ± SD) with (1) table PEEP: 11 ± 3 cm H2O; (2) minimal tidal recruitment PEEP: 22 ± 3 cm H2O; and (3) maximal oxygenation PEEP: 25 ± 4 cm H2O; P < 0.001. Table PEEP without recruitment maneuver caused highest lung collapse (28 ± 11% vs. 5 ± 5% vs. 4 ± 4%; P < 0.001), shunt perfusion (3.2 ± 0.8 l/min vs. 1.0 ± 0.8 l/min vs. 0.7 ± 0.6 l/min; P < 0.001) and dead space ventilation (2.9 ± 1.0 l/min vs. 1.5 ± 0.7 l/min vs. 1.7 ± 0.8 l/min; P < 0.001). Although resulting in different PEEP levels, minimal tidal recruitment and maximal oxygenation PEEP, both following a recruitment maneuver, had similar effects on regional ventilation/perfusion matching. Conclusions: When compared to table PEEP without a recruitment maneuver, both minimal tidal recruitment PEEP and maximal oxygenation PEEP following a recruitment maneuver decreased shunting and dead space ventilation, and the effects of minimal tidal recruitment PEEP and maximal oxygenation PEEP were comparable. In a porcine model of induced acute lung injury, with increased abdominal pressure caused by intraperitoneal saline infusion, using a crossover design, tracheostomized animals were ventilated using: (1) positive end-expiratory pressure (PEEP) table–based low PEEP without lung recruitment; (2) minimal tidal recruitment PEEP guided by electrical impedance tomography with recruitment; and (3) maximal oxygenation PEEP with recruitment. Using a PEEP table and no recruitment, compared with recruitment and either minimal tidal recruitment PEEP or maximal oxygenation PEEP, resulted in less delivered PEEP, and more lung collapse and regional ventilation/perfusion mismatch. The latter two methods had comparable results. Supplemental Digital Content is available in the text.

[1]  M. Hall.  National Heart, Lung, and Blood Institute , 2020, The Grants Register 2021.

[2]  S. Weber-Carstens,et al.  Clinical Guideline for Treating Acute Respiratory Insufficiency with Invasive Ventilation and Extracorporeal Membrane Oxygenation: Evidence-Based Recommendations for Choosing Modes and Setting Parameters of Mechanical Ventilation , 2019, Respiration.

[3]  T. Muders,et al.  Mechanical Ventilation Strategies Targeting Different Magnitudes of Collapse and Tidal Recruitment in Porcine Acid Aspiration-Induced Lung Injury , 2019, Journal of clinical medicine.

[4]  Benjamin Hentze,et al.  Electrical Impedance Tomography for Cardio-Pulmonary Monitoring , 2019, Journal of clinical medicine.

[5]  S. Leonhardt,et al.  A Modified Method to Assess Tidal Recruitment by Electrical Impedance Tomography , 2019, Journal of clinical medicine.

[6]  Fabian M. Troschel,et al.  Lung Recruitment in Obese Patients with Acute Respiratory Distress Syndrome , 2019, Anesthesiology.

[7]  P. Pelosi,et al.  Ventilation in patients with intra-abdominal hypertension: what every critical care physician needs to know , 2019, Annals of Intensive Care.

[8]  J. Starkopf,et al.  Incidence, Risk Factors, and Outcomes of Intra-Abdominal Hypertension in Critically Ill Patients—A Prospective Multicenter Study (IROI Study) , 2019, Critical care medicine.

[9]  D. Cook,et al.  Effect of Titrating Positive End-Expiratory Pressure (PEEP) With an Esophageal Pressure–Guided Strategy vs an Empirical High PEEP-FIO2 Strategy on Death and Days Free From Mechanical Ventilation Among Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial , 2019, JAMA.

[10]  C. Guérin,et al.  Effects of positive end-expiratory pressure strategy in supine and prone position on lung and chest wall mechanics in acute respiratory distress syndrome , 2018, Annals of Intensive Care.

[11]  R. Schmid,et al.  Impact of large volume paracentesis on respiratory parameters including transpulmonary pressure and on transpulmonary thermodilution derived hemodynamics: A prospective study , 2018, PloS one.

[12]  M. Amato,et al.  Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial , 2017, JAMA.

[13]  Giacomo Grasselli,et al.  Bedside selection of positive end-expiratory pressure by electrical impedance tomography in hypoxemic patients: a feasibility study , 2017, Annals of Intensive Care.

[14]  F. Rapetti,et al.  The future of mechanical ventilation: lessons from the present and the past , 2017, Critical Care.

[15]  Ewan C. Goligher,et al.  Fifty Years of Research in ARDS: Setting Positive End‐Expiratory Pressure in Acute Respiratory Distress Syndrome , 2017, American journal of respiratory and critical care medicine.

[16]  Ognjen Gajic,et al.  An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome , 2017, American journal of respiratory and critical care medicine.

[17]  Steffen Leonhardt,et al.  Chest electrical impedance tomography examination, data analysis, terminology, clinical use and recommendations: consensus statement of the TRanslational EIT developmeNt stuDy group , 2016, Thorax.

[18]  Anders Larsson,et al.  Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries. , 2016, JAMA.

[19]  Michael Quintel,et al.  The "baby lung" became an adult , 2016, Intensive Care Medicine.

[20]  H. Castro-Faria-Neto,et al.  Acute Respiratory Distress Syndrome: Role of Oleic Acid-Triggered Lung Injury and Inflammation , 2015, Mediators of inflammation.

[21]  M. Sampaolesi,et al.  Role of Inflammation in Muscle Homeostasis and Myogenesis , 2015, Mediators of inflammation.

[22]  J. Borges,et al.  Lung Inflammation Persists After 27 Hours of Protective Acute Respiratory Distress Syndrome Network Strategy and Is Concentrated in the Nondependent Lung , 2015, Critical care medicine.

[23]  Arthur S Slutsky,et al.  Driving pressure and survival in the acute respiratory distress syndrome. , 2015, The New England journal of medicine.

[24]  Laura Piqueras,et al.  Adjusting tidal volume to stress index in an open lung condition optimizes ventilation and prevents overdistension in an experimental model of lung injury and reduced chest wall compliance , 2015, Critical Care.

[25]  H. Robertson,et al.  Dead space: the physiology of wasted ventilation , 2014, European Respiratory Journal.

[26]  M. Matthay,et al.  The Association Between Physiologic Dead-Space Fraction and Mortality in Subjects With ARDS Enrolled in a Prospective Multi-Center Clinical Trial , 2014, Respiratory Care.

[27]  Tilo Winkler,et al.  Effect of Local Tidal Lung Strain on Inflammation in Normal and Lipopolysaccharide-Exposed Sheep* , 2014, Critical care medicine.

[28]  F. Guo,et al.  Positive end expiratory pressure titrated by transpulmonary pressure improved oxygenation and respiratory mechanics in acute respiratory distress syndrome patients with intra‐abdominal hypertension , 2013, Chinese medical journal.

[29]  P. V. van Heerden,et al.  Matching positive end-expiratory pressure to intra-abdominal pressure improves oxygenation in a porcine sick lung model of intra-abdominal hypertension , 2012, Critical Care.

[30]  Arthur S Slutsky,et al.  Acute Respiratory Distress Syndrome The Berlin Definition , 2012 .

[31]  M. Pinsky.  Heart lung interactions during mechanical ventilation , 2012, Current opinion in critical care.

[32]  Steffen Leonhardt,et al.  Tidal recruitment assessed by electrical impedance tomography and computed tomography in a porcine model of lung injury* , 2012, Critical care medicine.

[33]  P. Claus,et al.  Relationship between Abdominal Pressure, Pulmonary Compliance, and Cardiac Preload in a Porcine Model , 2012, Critical care research and practice.

[34]  L. Blanch,et al.  Beyond volutrauma in ARDS: the critical role of lung tissue deformation , 2011, Critical care.

[35]  C. Josten,et al.  Extrapolation from ten sections can make CT-based quantification of lung aeration more practicable , 2010, Intensive Care Medicine.

[36]  I. Cuthill,et al.  Reporting : The ARRIVE Guidelines for Reporting Animal Research , 2010 .

[37]  G. Musch,et al.  Measurement of Regional Specific Lung Volume Change Using Respiratory-Gated PET of Inhaled 13N-Nitrogen , 2010, Journal of Nuclear Medicine.

[38]  S. Russo,et al.  Lung opening and closing during ventilation of acute respiratory distress syndrome. , 2010, American journal of respiratory and critical care medicine.

[39]  Matthias Briel,et al.  Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. , 2010, JAMA.

[40]  D. Chemla,et al.  Hemodynamic impact of a positive end-expiratory pressure setting in acute respiratory distress syndrome: Importance of the volume status* , 2010, Critical care medicine.

[41]  Atul Malhotra,et al.  Mechanical ventilation guided by esophageal pressure in acute lung injury. , 2008, The New England journal of medicine.

[42]  Massimo Cressoni,et al.  Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome. , 2008, American journal of respiratory and critical care medicine.

[43]  M. Amato,et al.  Image reconstruction affects computer tomographic assessment of lung hyperinflation , 2008, Intensive Care Medicine.

[44]  Eric A Hoffman,et al.  CT-measured regional specific volume change reflects regional ventilation in supine sheep. , 2008, Journal of applied physiology.

[45]  Göran Hedenstierna,et al.  Electrical impedance tomography compared with thoracic computed tomography during a slow inflation maneuver in experimental models of lung injury* , 2008, Critical care medicine.

[46]  G. Musch,et al.  Relation between shunt, aeration, and perfusion in experimental acute lung injury. , 2008, American journal of respiratory and critical care medicine.

[47]  李红日,et al.  Progress of Acute Respiratory Distress Syndrome Caused by Pulmonary and Extrapulmonary Disease , 2007 .

[48]  Giovanni Gandini,et al.  Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome. , 2007, American journal of respiratory and critical care medicine.

[49]  Stephan H. Böhm,et al.  Use of dynamic compliance for open lung positive end‐expiratory pressure titration in an experimental study , 2007, Critical care medicine.

[50]  Robert M Kacmarek,et al.  Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome. , 2006, American journal of respiratory and critical care medicine.

[51]  Guillermo Bugedo,et al.  Lung recruitment in patients with the acute respiratory distress syndrome. , 2006, The New England journal of medicine.

[52]  黄亚明,et al.  European Society of Intensive Care Medicine , 2005, Intensive Care Medicine.

[53]  C. Putensen,et al.  Spontaneous breathing affects the spatial ventilation and perfusion distribution during mechanical ventilatory support* , 2005, Critical care medicine.

[54]  B. Lachmann,et al.  Open up the lung and keep the lung open , 1992, Intensive Care Medicine.

[55]  P. Pelosi,et al.  An increase of abdominal pressure increases pulmonary edema in oleic acid-induced lung injury. , 2004, American journal of respiratory and critical care medicine.

[56]  D. Schoenfeld,et al.  Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. , 2000, The New England journal of medicine.

[57]  P. Pelosi,et al.  Acute respiratory distress syndrome caused by pulmonary and extrapulmonary disease. Different syndromes? , 1998, American journal of respiratory and critical care medicine.

[58]  R. Nagai,et al.  Ventilation/perfusion ratios and simultaneous dual-radionuclide single-photon emission tomography with krypton-81m and technetium-99m macroaggregated albumin , 1997, European Journal of Nuclear Medicine.

[59]  G. Hedenstierna,et al.  V/Q distribution and correlation to atelectasis in anesthetized paralyzed humans. , 1996, Journal of applied physiology.

[60]  R. Rodríguez-Roisín,et al.  Contribution of multiple inert gas elimination technique to pulmonary medicine , 1994 .

[61]  J. Roca,et al.  Contribution of multiple inert gas elimination technique to pulmonary medicine 1 Series editor : R Rodriguez-Roisin Principles and information content of the multiple inert gas elimination technique , 2022 .

[62]  R W de Boer,et al.  Quantifying local lung perfusion and ventilation using correlated SPECT and CT data. , 1994, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[63]  A. Torresin,et al.  Relationships Between Lung Computed Tomographic Density, Gas Exchange, and PEEP in Acute Respiratory Failure , 1988, Anesthesiology.

[64]  D. Schuster,et al.  The effect of regional lung injury or alveolar hypoxia on pulmonary blood flow and lung water measured by positron emission tomography. , 1986, The American review of respiratory disease.

[65]  J. Lynch,et al.  Depression of cardiac output is a mechanism of shunt reduction in the therapy of acute respiratory failure. , 1980, Chest.

[66]  Peter M. Suter,et al.  Optimum End-Expiratory Airway Pressure in Patients with Acute Pulmonary Failure , 1975 .