Low Tidal Volume and High Positive End-Expiratory Pressure Mechanical Ventilation Results in Increased Inflammation and Ventilator-Associated Lung Injury in Normal Lungs

Hong, Caron M.; Xu, Da-Zhong; Lu, Quan; Cheng, Yunhui; Pisarenko, Vadim; Doucet, Daniel; Brown, Margaret R.; Aisner, Seena C.; Zhang, Chunxiang; Deitch, Edwin A.; Delphin, Ellise

doi:10.1213/ane.0b013e3181cfc416

Cited by 56 publications

(50 citation statements)

References 30 publications

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“…This is in agreement with previous studies where VT close to 15 mL/kg were maintained with PIP between 22 (Moens et al 1998) and 30 cmH 2 O (Hubbell et al 2011). In humans under general anesthesia, VT as low as 6 mL/kg did not induce more lung atelectasis than traditional VT (Cai et al 2007), but high pressures and large volumes induced more lung injury (Hong et al 2010). Still, the influence of PIP and VT on development of atelectasis in healthy lungs of horses during general anesthesia is not well characterized.…”

Section: Discussionsupporting

confidence: 92%

Impact of low inspired oxygen fraction on oxygenation in clinical horses under general anesthesia

Levionnois¹,

Zuehlke²,

Kuhn³

et al. 2016

PHK

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Summary:The objective was to compare the use of 0.3 and >0.95 oxygen inspired fraction during general anesthesia in horses. Forty client-owned adult horses were anesthetized in dorsal or in lateral recumbency with isoflurane in oxygen and randomly allocated to receive inspiratory fraction of oxygen >0.95 (group HIGH) or 0.3 (group LOW). Mechanical ventilation was provided using pressure controlled mode. Arterial blood gas analysis was performed before, during and after general anesthesia. The group LOW obtained lower intra-operative PaO 2 values but better indices of venous admixture than the group HIGH. The PaO 2 further decreased during the recovery, without significant differences between groups. Even though the use of lower oxygen inspired fraction (0.3) tended to improve pulmonary function during general anesthesia, it markedly decreased safety as a result of hypoxemia. During the recovery, no difference was observed between groups for the arterial oxygenation such that lower intra-anesthetic oxygen inspired fraction did not provide any advantages.

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Section: Discussionsupporting

confidence: 92%

Impact of low inspired oxygen fraction on oxygenation in clinical horses under general anesthesia

Levionnois¹,

Zuehlke²,

Kuhn³

et al. 2016

PHK

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“…The general principle that shortening exhalation times can prevent end-expiratory collapse without an increase in intrinsic PEEP, however, was also demonstrated in the study by Syringe et al (34), in that study by increasing RR. Other potential mechanisms of VILI that could accompany IRV, such as higher static stretch and higher mean airway pressures, possibly resulting in increased inflammation (35)(36)(37)(38), were not addressed in our study. IRV also carries some risk of increasing intrinsic PEEP, if not carefully monitored.…”

Section: Discussionmentioning

confidence: 95%

Influence of Inspiration to Expiration Ratio on Cyclic Recruitment and Derecruitment of Atelectasis in a Saline Lavage Model of Acute Respiratory Distress Syndrome*

Boehme

Bentley

Hartmann

et al. 2015

Critical Care Medicine

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e65Objective: Cyclic recruitment and derecruitment of atelectasis can occur during mechanical ventilation, especially in injured lungs. Experimentally, cyclic recruitment and derecruitment can be quantified by respiration-dependent changes in Pao 2 (ΔPao 2 ), reflecting the varying intrapulmonary shunt fraction within the respiratory cycle. This study investigated the effect of inspiration to expiration ratio upon ΔPao 2 and Horowitz index. Design: Prospective randomized study.Setting: Laboratory investigation. Subjects: Piglets, average weight 30 ± 2 kg. Interventions: At respiratory rate 6 breaths/min, end-inspiratory pressure (P endinsp ) 40 cm H 2 O, positive end-expiratory pressure 5 cm H 2 O, and Fio 2 1.0, measurements were performed at randomly set inspiration to expiration ratios during baseline healthy and mild surfactant depletion injury. Lung damage was titrated by repetitive surfactant washout to induce maximal cyclic recruitment and derecruitment as measured by multifrequency phase fluorimetry. Regional ventilation distribution was evaluated by electrical impedance tomography.Step changes in airway pressure from 5 to 40 cm H 2 O and vice versa were performed after lavage to calculate Po 2 -based recruitment and derecruitment time constants (TAU). Measurements and Main Results: In baseline healthy, cyclic recruitment and derecruitment could not be provoked, whereas in model acute respiratory distress syndrome, the highest ΔPao 2 were routinely detected at an inspiration to expiration ratio of 1:4 (range, 52-277 torr [6.9-36.9 kPa]). Shorter expiration time reduced cyclic recruitment and derecruitment significantly (158 ± 85 torr [21.1 ± 11.3 kPa] [inspiration to expiration ratio, 1:4]; 25 ± 12 torr [3.3 ± 1.6 kPa] [inspiration to expiration ratio, 4:1]; p < 0.0001), whereas the Pao 2 /Fio 2 ratio increased (267 ± 50 [inspiration to expiration ratio, 1:4]; 424 ± 53 [inspiration to expiration ratio, 4:1]; p < 0.0001). Correspondingly, regional ventilation redistributed toward dependent lung regions (p < 0.0001). Recruitment was much faster (TAU: fast 1.6 s [78%]; slow 9.2 s) than derecruitment (TAU: fast 3.1 s [87%]; slow 17.7 s) (p = 0.0078). Conclusions: Inverse ratio ventilation minimizes cyclic recruitment and derecruitment of atelectasis in an experimental model of surfactant-depleted pigs. Time constants for recruitment and derecruitment, and regional ventilation distribution, reflect these findings and highlight the time dependency of cyclic recruitment and derecruitment. (Crit Care Med 2015; 43:e65-e74)

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“…16,17 Indeed, recently an experimental study suggested that such strategy might even lead to increased inflammation and lung injury in normal lungs. 18 Despite these pathophysiological considerations, the use of PEEP in the operating room is controversial. Recently, an observational study conducted in 28 centers in France revealed that most patients undergoing general surgery were ventilated without PEEP.…”

Section: Severgnini Et Almentioning

confidence: 99%

Protective Mechanical Ventilation during General Anesthesia for Open Abdominal Surgery Improves Postoperative Pulmonary Function

et al. 2013

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Background: The impact of intraoperative ventilation on postoperative pulmonary complications is not defined. The authors aimed at determining the effectiveness of protective mechanical ventilation during open abdominal surgery on a modified Clinical Pulmonary Infection Score as primary outcome and postoperative pulmonary function. Methods: Prospective randomized, open-label, clinical trial performed in 56 patients scheduled to undergo elective open abdominal surgery lasting more than 2 h. Patients were assigned by envelopes to mechanical ventilation with tidal volume of 9 ml/kg ideal body weight and zero-positive end-expiratory pressure (standard ventilation strategy) or tidal volumes of 7 ml/kg ideal body weight, 10 cm H2O positive end-expiratory pressure, and recruitment maneuvers (protective ventilation strategy). Modified Clinical Pulmonary Infection Score, gas exchange, and pulmonary functional tests were measured preoperatively, as well as at days 1, 3, and 5 after surgery. Results: Patients ventilated protectively showed better pulmonary functional tests up to day 5, fewer alterations on chest x-ray up to day 3 and higher arterial oxygenation in air at days 1, 3, and 5 (mmHg; mean ± SD): 77.1 ± 13.0 versus 64.9 ± 11.3 (P = 0.0006), 80.5 ± 10.1 versus 69.7 ± 9.3 (P = 0.0002), and 82.1 ± 10.7 versus 78.5 ± 21.7 (P = 0.44) respectively. The modified Clinical Pulmonary Infection Score was lower in the protective ventilation strategy at days 1 and 3. The percentage of patients in hospital at day 28 after surgery was not different between groups (7 vs. 15% respectively, P = 0.42). Conclusion: A protective ventilation strategy during abdominal surgery lasting more than 2 h improved respiratory function and reduced the modified Clinical Pulmonary Infection Score without affecting length of hospital stay.

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Low Tidal Volume and High Positive End-Expiratory Pressure Mechanical Ventilation Results in Increased Inflammation and Ventilator-Associated Lung Injury in Normal Lungs

Abstract: Comparing intraoperative strategies, ventilation with high PEEP resulted in increased production of inflammatory markers. Low PEEP resulted in lower levels of inflammatory markers. High Vt/low PEEP resulted in less histologic lung injury.

Cited by 56 publications

References 30 publications

Impact of low inspired oxygen fraction on oxygenation in clinical horses under general anesthesia

Impact of low inspired oxygen fraction on oxygenation in clinical horses under general anesthesia

Influence of Inspiration to Expiration Ratio on Cyclic Recruitment and Derecruitment of Atelectasis in a Saline Lavage Model of Acute Respiratory Distress Syndrome*

Protective Mechanical Ventilation during General Anesthesia for Open Abdominal Surgery Improves Postoperative Pulmonary Function

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