Matching positive end-expiratory pressure to intra-abdominal pressure improves oxygenation in a porcine sick lung model of intra-abdominal hypertension

Abstract

IntroductionIntra-abdominal hypertension (IAH) causes atelectasis, reduces lung volumes and increases respiratory system elastance. Positive end-expiratory pressure (PEEP) in the setting of IAH and healthy lungs improves lung volumes but not oxygenation. However, critically ill patients with IAH often suffer from acute lung injury (ALI). This study, therefore, examined the respiratory and cardiac effects of positive end-expiratory pressure in an animal model of IAH, with sick lungs.MethodsNine pigs were anesthetized and ventilated (48 +/- 6 kg). Lung injury was induced with oleic acid. Three levels of intra-abdominal pressure (baseline, 18, and 22 mmHg) were randomly generated. At each level of intra-abdominal pressure, three levels of PEEP were randomly applied: baseline (5 cmH2O), moderate (0.5 × intra-abdominal pressure), and high (1.0 × intra-abdominal pressure). We measured end-expiratory lung volumes, arterial oxygen levels, respiratory mechanics, and cardiac output 10 minutes after each new IAP and PEEP setting.ResultsAt baseline PEEP, IAH (22 mmHg) decreased oxygen levels (-55%, P <0.001) and end-expiratory lung volumes (-45%, P = 0.007). At IAP of 22 mmHg, moderate and high PEEP increased oxygen levels (+60%, P = 0.04 and +162%, P <0.001) and end-expiratory lung volume (+44%, P = 0.02 and +279%, P <0.001) and high PEEP reduced cardiac output (-30%, P = 0.04). Shunt and dead-space fraction inversely correlated with oxygen levels and end-expiratory lung volumes. In the presence of IAH, lung, chest wall and respiratory system elastance increased. Subsequently, PEEP decreased respiratory system elastance by decreasing chest wall elastance.ConclusionsIn a porcine sick lung model of IAH, PEEP matched to intra-abdominal pressure led to increased lung volumes and oxygenation and decreased chest wall elastance shunt and dead-space fraction. High PEEP decreased cardiac output. The study shows that lung injury influences the effects of IAH and PEEP on oxygenation and respiratory mechanics. Our findings support the application of PEEP in the setting of acute lung injury and IAH.

The polycompartment syndrome: a concise state-of-the-art review

“…Important issues to consider include: 1. PEEP should be set to counteract ITP and IAP while at the same time avoiding over-inflation of already well-ventilated regions of lung [34,35]. [42].…”

Anesthesia and Intraoperative Management in Liver Surgery

“…Regli and colleagues [ 17 ] reported an increase of end-expiratory lung volume and gas exchange with a reduction of pulmonary shunt and dead space fraction, when adequate level of PEEP was applied, especially in the presence of intraabdominal hypertension. Although the application of high levels of PEEP carries the risk of barotrauma, PEEP itself may have a negative impact on hemodynamics.…”

PEEP Titration: New Horizons

“…Recent preclinical work investigated setting PEEP relative to the measured intra-abdominal pressure, in animal models. [24][25][26][27] In swine with intra-abdominal hypertension and normal lungs, PEEP set at half the intra-abdominal pressure returned the functional residual capacity (FRC) to the value seen with normal intra-abdominal pressure. In an oleic acid injury model, PEEP set at half the intra-abdominal pressure improved oxygenation but did not significantly improve FRC.…”