New and conventional strategies for lung recruitment in acute respiratory distress syndrome

Pelosi, Paolo; Abreu, Marcelo Gama de; Rocco, Patricia R. M.

doi:10.1186/cc8851

Cited by 40 publications

(20 citation statements)

References 51 publications

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“…Using lung separation combined with extracorporeal Co 2 removal, which was necessary to avoid excessive hypercapnia with resulting severe respiratory acidosis caused by one-lung ventilation with low V T , we isolated the individual contributions of volutrauma and atelectrauma on lung inflammation during VILI. We opted for a recruitment maneuver with sustained inflation because it is highly effective in opening lungs in a model of moderate ARDS (20, 22). In addition, after recruiting lungs and differently from clinical lung protective MV, we selected levels of PEEP according to the pressure–volume curve of the respiratory system, in order to induce predominantly volutrauma or atelectrauma.…”

Section: Discussionmentioning

confidence: 99%

“…In ARDS, to fulfill its potential protective effects, a proper titrated-individualized PEEP needs be preceded by a proper titrated-individualized maximum recruitment strategy. Then, PEEP not only may decrease atelectrauma but also has the potential to reduce volutrauma (20, 22). However, the distribution of aeration might be nonhomogenous, and certain lung regions can be under higher static stress and strain.…”

Section: Discussionmentioning

confidence: 99%

“…The sample size calculation for testing the primary hypothesis ( K i S is higher in volutrauma than atelectrauma in pigs) was based on effect estimates obtained from pilot studies and data from the literature (20). Accordingly, we expected a sample size of five animals to provide the appropriate power (1 – β = 0.8) to identify significant (α = 0.05) differences in K i S between volutrauma and atelectrauma, considering an expected effect size d equal to 2.20, and Wilcoxon and Mann-Whitney tests.…”

Section: Methodsmentioning

confidence: 99%

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Comparative Effects of Volutrauma and Atelectrauma on Lung Inflammation in Experimental Acute Respiratory Distress Syndrome

Güldner

Braune

Ball

et al. 2016

Critical Care Medicine

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Objective Volutrauma and atelectrauma promote ventilator-induced lung injury, but their relative contribution to inflammation in ventilator-induced lung injury is not well established. The aim of this study was to determine the impact of volutrauma and atelectrauma on the distribution of lung inflammation in experimental acute respiratory distress syndrome. Design Laboratory investigation. Setting University-hospital research facility. Subjects Ten pigs (five per group; 34.7–49.9 kg) Interventions Animals were anesthetized and intubated, and saline lung lavage was performed. Lungs were separated with a double-lumen tube. Following lung recruitment and decremental positive end-expiratory pressure trial, animals were randomly assigned to 4 hours of ventilation of the left (ventilator-induced lung injury) lung with tidal volume of approximately 3 mL/kg and 1) high positive end-expiratory pressure set above the level where dynamic compliance increased more than 5% during positive end-expiratory pressure trial (volutrauma); or 2) low positive end-expiratory pressure to achieve driving pressure comparable with volutrauma (atelectrauma). The right (control) lung was kept on continuous positive airway pressure of 20 cm H2O, and Co2 was partially removed extracorporeally. Measurements and Main Results Regional lung aeration, specific [18F]fluorodeoxyglucose uptake rate, and perfusion were assessed using computed and positron emission tomography. Volutrauma yielded higher [18F]fluorodeoxyglucose uptake rate in the ventilated lung compared with atelectrauma (median [interquartile range], 0.017 [0.014–0.025] vs 0.013 min−1 [0.010–0.014min−1]; p < 0.01), mainly in central lung regions. Volutrauma yielded higher [18F]fluorodeoxyglucose uptake rate in ventilator-induced lung injury versus control lung (0.017 [0.014–0.025] vs 0.011 min−1 [0.010–0.016min−1]; p < 0.05), whereas atelectrauma did not. Volutrauma decreased blood fraction at similar perfusion and increased normally as well as hyper-aerated lung compartments and tidal hyperaeration. Atelectrauma yielded higher poorly and nonaerated lung compartments, and tidal recruitment. Driving pressure increased in atelectrauma. Conclusions In this model of acute respiratory distress syndrome, volutrauma promoted higher lung inflammation than atelectrauma at comparable low tidal volume and lower driving pressure, suggesting that static stress and strain are major determinants of ventilator-induced lung injury.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Comparative Effects of Volutrauma and Atelectrauma on Lung Inflammation in Experimental Acute Respiratory Distress Syndrome

Güldner

Braune

Ball

et al. 2016

Critical Care Medicine

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“…A recent PP meta-analysis suggested a positive result on oxygenation and mortality and that VILI may be reduced or delayed during PP [37,40,41]. The combination of PP and RM may be a safe strategy to use for improvement of oxygenation and to avoid VILI.…”

Section: Discussionmentioning

confidence: 99%

Prone position and recruitment manoeuvre: the combined effect improves oxygenation

et al. 2011

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IntroductionAmong the various methods for improving oxygenation while decreasing the risk of ventilation-induced lung injury in patients with acute respiratory distress syndrome (ARDS), a ventilation strategy combining prone position (PP) and recruitment manoeuvres (RMs) can be practiced. We studied the effects on oxygenation of both RM and PP applied in early ARDS patients.MethodsWe conducted a prospective study. Sixteen consecutive patients with early ARDS fulfilling our criteria (ratio of arterial oxygen partial pressure to fraction of inspired oxygen (PaO2/FiO2) 98.3 ± 28 mmHg; positive end expiratory pressure, 10.7 ± 2.8 cmH2O) were analysed. Each patient was ventilated in both the supine position (SP) and the PP (six hours in each position). A 45 cmH2O extended sigh in pressure control mode was performed at the beginning of SP (RM1), one hour after turning to the PP (RM2) and at the end of the six-hour PP period (RM3).ResultsThe mean arterial oxygen partial pressure (PaO2) changes after RM1, RM2 and RM3 were 9.6%, 15% and 19%, respectively. The PaO2 improvement after a single RM was significant after RM3 only (P < 0.05). Improvements in PaO2 level and PaO2/FiO2 ratio were transient in SP but durable during PP. PaO2/FiO2 ratio peaked at 218 mmHg after RM3. PaO2/FiO2 changes were significant only after RM3 and in the pulmonary ARDS group (P = 0.008). This global strategy had a benefit with regard to oxygenation: PaO2/FiO2 ratio increased from 98.3 mmHg to 165.6 mmHg 13 hours later at the end of the study (P < 0.05). Plateau airway pressures decreased after each RM and over the entire PP period and significantly after RM3 (P = 0.02). Some reversible side effects such as significant blood arterial pressure variations were found when extended sighs were performed.ConclusionsIn our study, interventions such as a 45 cmH2O extended sigh during PP resulted in marked oxygenation improvement. Combined RM and PP led to the highest increase in PaO2/FiO2 ratio without major clinical side effects.

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“…Recruitment maneuvers in patients with ARDS may have a beneficial effect on the respiratory function [7]. In the presence of IAH and increased chest wall elastance, the inspiratory pressure of the respiratory system applied during recruitment maneuver should be higher than usually applied, in order to achieve an inspiratory trans-pulmonary pressure that is large enough enough to reopen collapsed alveoli.…”

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confidence: 99%

Mechanical ventilation and intra-abdominal hypertension: 'Beyond Good and Evil'

Pelosi

Vargas

2012

Crit Care

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Intra-abdominal hypertension is frequent in surgical and medical critically ill patients. Intra-abdominal hypertension has a serious impact on the function of respiratory as well as peripheral organs. In the presence of alveolar capillary damage, which occurs in acute respiratory distress syndrome (ARDS), intra-abdominal hypertension promotes lung injury as well as edema, impedes the pulmonary lymphatic drainage, and increases intra-thoracic pressures, leading to atelectasis, airway closure, and deterioration of respiratory mechanics and gas exchange. The optimal setting of mechanical ventilation and its impact on respiratory function and hemodynamics in ARDS associated with intra-abdominal hypertension are far from being assessed. We suggest that the optimal ventilator management of patients with ARDS and intra-abdominal hypertension would include the following: (a) intra-abdominal, esophageal pressure, and hemodynamic monitoring; (b) ventilation setting with protective tidal volume, recruitment maneuver, and level of positive end-expiratory pressure set according to the 'best' compliance of the respiratory system or the lung; (c) deep sedation with or without neuromuscular paralysis in severe ARDS; and (d) open abdomen in selected patients with severe abdominal compartment syndrome.

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New and conventional strategies for lung recruitment in acute respiratory distress syndrome

Cited by 40 publications

References 51 publications

Comparative Effects of Volutrauma and Atelectrauma on Lung Inflammation in Experimental Acute Respiratory Distress Syndrome

Comparative Effects of Volutrauma and Atelectrauma on Lung Inflammation in Experimental Acute Respiratory Distress Syndrome

Prone position and recruitment manoeuvre: the combined effect improves oxygenation

Mechanical ventilation and intra-abdominal hypertension: 'Beyond Good and Evil'

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