Effects of Vascular Flow and PEEP in a Multiple Hit Model of Lung Injury in Isolated Perfused Rabbit Lungs

Piacentini, Enrique; López-Aguilar, Josefina; García-Martín, Carolina; Villagrá, Ana; Saenz-Valiente, Alicia; Murias, Tiberio Feliz; Fernández-Segoviano, Pilar; Hotchkiss, John R.; Blanch, Lluís

doi:10.1097/ta.0b013e31813e0904

Cited by 16 publications

(15 citation statements)

References 34 publications

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“…Pulmonary edema caused by an increase in vascular flow and pulmonary artery pressure (35 mmHg) was significantly reduced with the addition of PEEP (15 cmH 2 O), however, the protective effect of PEEP was lost when a second hit (oleic acid) was infused into the circuit of an isolated perfused rabbit lung preparation (106).…”

Section: Synthesis Reviewmentioning

confidence: 99%

“…The majority of studies focused on the effect of changes in PEEP (23,29,37,47,55,78,93,106,115,116,136) with a smaller number investigating the effect of VT and PEEP on lung fluid balance (23,29). The data demonstrate that if sufficient preemptive PEEP is applied, lung water will be significantly diminished in multiple lung injury models including high vascular pressure (23,47,106,116), high alveolar surface tension (78), high endothelial permeability (29,55,93,115), and high airway pressure (37,136). Also, PEEP is most effective at reducing edema when applied soon after injury (47,114).…”

Section: Physiological Evidence That the Mechanical Breath Can Block mentioning

confidence: 99%

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Impact of mechanical ventilation on the pathophysiology of progressive acute lung injury

Nieman

Gatto

Habashi

2015

Journal of Applied Physiology

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Nieman GF, Gatto LA, Habashi NM. Impact of mechanical ventilation on the pathophysiology of progressive acute lung injury. J Appl Physiol 119: 1245-1261. First published October 15, 2015 doi:10.1152/japplphysiol.00659.2015The earliest description of what is now known as the acute respiratory distress syndrome (ARDS) was a highly lethal double pneumonia. Ashbaugh and colleagues (Ashbaugh DG, Bigelow DB, Petty TL, Levine BE Lancet 2: 319-323, 1967) correctly identified the disease as ARDS in 1967. Their initial study showing the positive effect of mechanical ventilation with positive end-expiratory pressure (PEEP) on ARDS mortality was dampened when it was discovered that improperly used mechanical ventilation can cause a secondary ventilator-induced lung injury (VILI), thereby greatly exacerbating ARDS mortality. This Synthesis Report will review the pathophysiology of ARDS and VILI from a mechanical stress-strain perspective. Although inflammation is also an important component of VILI pathology, it is secondary to the mechanical damage caused by excessive strain. The mechanical breath will be deconstructed to show that multiple parameters that comprise the breath-airway pressure, flows, volumes, and the duration during which they are applied to each breath-are critical to lung injury and protection. Specifically, the mechanisms by which a properly set mechanical breath can reduce the development of excessive fluid flux and pulmonary edema, which are a hallmark of ARDS pathology, are reviewed. Using our knowledge of how multiple parameters in the mechanical breath affect lung physiology, the optimal combination of pressures, volumes, flows, and durations that should offer maximum lung protection are postulated. acute lung injury; lung; pathophysiology ventilator; VILI THE POLIO EPIDEMIC OF 1916 inspired many treatment attempts including vitamin C therapy, hydrotherapy, and electrotherapy, but no effective therapy was found until Philip Drinker's group invented negative pressure mechanical ventilation-the iron lung. Their landmark paper, "The use of a new apparatus for the prolonged administration of artificial respiration: I. A fatal case of poliomyelitis," published in 1929, demonstrated the effective clinical use of this device (Fig. 1) (38). The concept of conversion from negative to positive pressure ventilation was based on technical advances that were made during World War II to deliver pressurized oxygen to high-altitude fighter and bomber pilots. Concomitant with these technologic advances in mechanical ventilation was the realization that what was originally thought to be a universally fatal form of double pneumonia was indeed a unique clinical entity that we now call the acute respiratory distress syndrome (ARDS). In a 1967 seminal paper published in The Lancet, Ashbaugh et al. (10) first identified and described ARDS as a collection of pathologic abnormalities that can be caused by many unrelated insults such as sepsis, hemorrhagic shock, pneumonia, and trauma to name a few. The disease and the ventil...

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Section: Synthesis Reviewmentioning

confidence: 99%

Section: Physiological Evidence That the Mechanical Breath Can Block mentioning

confidence: 99%

Impact of mechanical ventilation on the pathophysiology of progressive acute lung injury

Nieman

Gatto

Habashi

2015

Journal of Applied Physiology

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“…34 The presence of numerous factors producing lung derecruitment and inflammation during abdominal surgery, such as muscle paralysis, direct and indirect diaphragmatic compression, surgical retraction, manipulation of abdominal contents, endotoxemia, 35 bacteremia, 36 supine position, and diaphragmatic dysfunction 37 compound to produce a multihit injury. 38 This contrasts to neurological surgery with lower incidences of postoperative respiratory complications reported up to 24% 39 and less intraoperative factors for lung derecruitment. Our results of larger benefit of PEEP in major abdominal surgery are consistent with such differential mechanisms of pulmonary burden in the different surgery types, and indicate that individualization of PEEP to type of surgery is important to optimize outcomes.…”

Section: Discussionmentioning

confidence: 97%

Differential Effects of Intraoperative Positive End-expiratory Pressure (PEEP) on Respiratory Outcome in Major Abdominal Surgery Versus Craniotomy

et al. 2016

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Objectives In this study, we examined whether (1) positive end-expiratory pressure (PEEP) has a protective effect on the risk of major postoperative respiratory complications in a cohort of patients undergoing major abdominal surgeries and craniotomies, and (2) the effect of PEEP is differed by surgery type. Background Protective mechanical ventilation with lower tidal volumes and PEEP reduces compounded postoperative complications after abdominal surgery. However, data regarding the use of intraoperative PEEP is conflicting. Methods In this observational study, we included 5915 major abdominal surgery patients and 5063 craniotomy patients. Analysis was performed using multivariable logistic regression. The primary outcome was a composite of major postoperative respiratory complications (respiratory failure, reintubation, pulmonary edema, and pneumonia) within 3 days of surgery. Results Within the entire study population (major abdominal surgeries and craniotomies), we found an association between application of PEEP ≥5cmH2O and a decreased risk of postoperative respiratory complications compared with PEEP <5cmH2O. Application of PEEP >5cmH2O was associated with a significant lower odds of respiratory complications in patients undergoing major abdominal surgery (odds ratio 0.53, 95% confidence interval 0.39 – 0.72), effects that translated to deceased hospital length of stay [median hospital length of stay : 6 days (4–9 days), incidence rate ratios for each additional day: 0.91 (0.84 - 0.98)], whereas PEEP >5cmH2O was not significantly associated with reduced odds of respiratory complications or hospital length of stay in patients undergoing craniotomy. Conclusions The protective effects of PEEP are procedure specific with meaningful effects observed in patients undergoing major abdominal surgery. Our data suggest that default mechanical ventilator settings should include PEEP of 5–10cmH2O during major abdominal surgery.

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“…Moreover, these effects are aggravated by ventilation at rapid respiratory rates with concomitant increases in pulmonary artery pressure [15 & ] and by high cardiac output [16,17]. In this context, PEEP reduces transmural pressure (decreases strain) and attenuates edema formation and lung hemorrhage [18]. These data highlight the interactive nature of the processes and cofactors involved in the modulation of VILI, like global and/or regional pulmonary hemodynamics; the presence, type, and timing of secondary lung insults; and interactions between regional heterogeneity of pulmonary perfusion and regionally heterogeneous peak airspace strains.…”

Section: Key Pointsmentioning

confidence: 99%

Organ crosstalk during acute lung injury, acute respiratory distress syndrome, and mechanical ventilation

Quilez

López-Aguilar

Blanch

2012

Current Opinion in Critical Care

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Effects of Vascular Flow and PEEP in a Multiple Hit Model of Lung Injury in Isolated Perfused Rabbit Lungs

Abstract: Under these experimental conditions, PEEP attenuates lung injury in the setting of high vascular flow. The protective effect of PEEP is lost in a two-hit model of lung injury.

Cited by 16 publications

References 34 publications

Impact of mechanical ventilation on the pathophysiology of progressive acute lung injury

Impact of mechanical ventilation on the pathophysiology of progressive acute lung injury

Differential Effects of Intraoperative Positive End-expiratory Pressure (PEEP) on Respiratory Outcome in Major Abdominal Surgery Versus Craniotomy

Organ crosstalk during acute lung injury, acute respiratory distress syndrome, and mechanical ventilation

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