Effects of pressure support ventilation on ventilator-induced lung injury in mild acute respiratory distress syndrome depend on level of positive end-expiratory pressure

Magalhães, Paulo; Padilha, Gisele de A.; Moraes, Lillian; Santos, Carlos Antônio Cabral; Maia, Lígia de Albuquerque; Braga, Cássia L.; Duarte, Mariano; Andrade, Lívia Barboza de; Schanaider, Alberto; Capellozzi, Vera L.; Huhle, Robert; Abreu, Marcelo Gama de; Pelosi, Paolo; Rocco, Patricia R. M.; Silva, Pedro L.

doi:10.1097/eja.0000000000000763

Cited by 24 publications

(30 citation statements)

References 43 publications

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“…The observation that lung inflammation was decreased with higher compared to lower PEEP, mainly in ventral lung zones, is in line with previous data from our group in small animals (26), and can be explained by different factors. First, higher PEEP yielded increased normally aerated with decreased poorly aerated lung tissue.…”

Section: Discussionsupporting

confidence: 92%

Effects of Positive End-Expiratory Pressure and Spontaneous Breathing Activity on Regional Lung Inflammation in Experimental Acute Respiratory Distress Syndrome

Kiss

Bluth

Braune

et al. 2019

Critical Care Medicine

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Section: Discussionsupporting

confidence: 92%

Effects of Positive End-Expiratory Pressure and Spontaneous Breathing Activity on Regional Lung Inflammation in Experimental Acute Respiratory Distress Syndrome

Kiss

Bluth

Braune

et al. 2019

Critical Care Medicine

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“…This regional recruitment is different from that obtained by PEEP increase, which may overinflate those regions already inflated, usually observed in nonrecruitable lungs (29). Additionally, in rats, it has been shown that gentle spontaneous breathing with esophageal pressure variation around 2. level reduced inflammatory mediators as also maintained epithelial integrity (30). The esophageal decay and the generated P L performed in rats represents one-half to that performed in healthy humans (31), reaching values around 5 cmH 2 O for a quite breathing pattern.…”

Section: P L During Assisted Spontaneous Breathing: Unraveling Effectormentioning

confidence: 80%

Regional distribution of transpulmonary pressure

Silva¹,

Abreu²

2018

Ann. Transl. Med

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The pressure across the lung, so-called transpulmonary pressure (P L), represents the main force acting toward to provide lung movement. During mechanical ventilation, P L is provided by respiratory system pressurization, using specific ventilator setting settled by the operator, such as: tidal volume (V T), positive end-expiratory pressure (PEEP), respiratory rate (RR), and inspiratory airway flow. Once P L is developed throughout the lungs, its distribution is heterogeneous, being explained by the elastic properties of the lungs and pleural pressure gradient. There are different methods of P L calculation, each one with importance and some limitations. Among the most known, it can be quoted: (I) direct measurement of P L ; (II) elastance derived method at end-inspiration of P L ; (III) transpulmonary driving pressure. Recent studies using pleural sensors in large animal models as also in human cadaver have added new and important information about P L heterogeneous distribution across the lungs. Due to this heterogeneous distribution, lung damage could happen in specific areas of the lung. In addition, it is widely accepted that high P L can cause lung damage, however the way it is delivered, whether it's compressible or tensile, may also further damage despite the values of P L achieved. According to heterogeneous distribution of P L across the lungs, the interstitium and lymphatic vessels may also interplay to disseminate lung inflammation toward peripheral organs through thoracic lymph tracts. Thus, it is conceivable that juxta-diaphragmatic area associated strong efforts leading to high values of P L may be a source of dissemination of inflammatory cells, large molecules, and plasma contents able to perpetuate inflammation in distal organs.

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“…A higher PEEP minimized dependent lung injury via lung stress and stretch in adults with severe ARDS and animal models of ARDS, 28 whereas a PEEP of 5 cm H 2 O but not a PEEP of 2 cm H 2 O reduced lung damage and inflammatory markers. 29 Our study had strengths and some limitations. To our knowledge, this was the first study to describe respiratory muscle function changes at different levels of CPAP in premature infants on ventilation.…”

Section: Discussionmentioning

confidence: 99%

Ventilation Efficiency and Respiratory Muscle Function at Different Levels of CPAP in Intubated Prematurely Born Infants

Dassios

Dixon²,

Greenough

2018

Respir Care

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BACKGROUND: CPAP improves respiratory function in prematurely born infants by establishing and maintaining functional residual capacity, but the level of CPAP that optimizes respiratory function has not been adequately described. We compared ventilation efficiency and respiratory muscle function at different levels of CPAP. METHODS: We studied spontaneously breathing, intubated convalescent premature infants at King's College Hospital NHS Foundation Trust and calculated the ventilation efficiency index and the respiratory muscle time constant of relaxation () at the end of 3 consecutive 5-min periods at 4, 6, and 8 cm H 2 O of CPAP delivered in random order. RESULTS: Between February 2016 and August 2016, 38 infants with a median gestational age of 27 (interquartile range [IQR], 25؊30) weeks and a median birthweight of 0.88 (IQR, 0.73-1.02) kg were studied. At a CPAP level of 6 cm H 2 O, the median ventilation efficiency index was higher (1.52 [IQR, 1.02-2.27]) and median was lower (15.6 [IQR, 10.1-21.3]) s/cm H 2 O] compared with the median ventilation efficiency index (0.75 [IQR, 0.56-1.03]) and median (23.3 [IQR, 15.4-35.2] sec/cm H 2 O) at CPAP of 4 cm H 2 O (P < .001 for both). At a CPAP level of 8 cm H 2 O, median ventilation efficiency index was significantly lower (1.27 [IQR, 1.04-1.91]) and median was not significantly different (11.2 [IQR, 8.3-18.9] s/cm H 2 O) compared with ventilation efficiency index and at CPAP of 6 cm H 2 O (P < .001 and P ‫؍‬ .12, respectively). After multiple logistic regression, the level of CPAP was independently associated with the ventilation efficiency index (adjusted P < .001) and (adjusted P ‫؍‬ .003). CONCLUSIONS: Increasing the level of CPAP from 4 to 6 cm H 2 O was associated with enhanced ventilation efficiency and respiratory muscle function in convalescent premature infants on ventilation, but there was no further benefit from increasing the pressure >6 cm H 2 O.

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Effects of pressure support ventilation on ventilator-induced lung injury in mild acute respiratory distress syndrome depend on level of positive end-expiratory pressure

Abstract: During PSV, PEEP of 5 cmH2O, but not a PEEP of 2 cmH2O, reduced lung damage and inflammatory markers while maintaining epithelial cell integrity.

Cited by 24 publications

References 43 publications

Effects of Positive End-Expiratory Pressure and Spontaneous Breathing Activity on Regional Lung Inflammation in Experimental Acute Respiratory Distress Syndrome

Effects of Positive End-Expiratory Pressure and Spontaneous Breathing Activity on Regional Lung Inflammation in Experimental Acute Respiratory Distress Syndrome

Regional distribution of transpulmonary pressure

Ventilation Efficiency and Respiratory Muscle Function at Different Levels of CPAP in Intubated Prematurely Born Infants

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