Physiological effects of an open lung ventilatory strategy titrated on elastance-derived end-inspiratory transpulmonary pressure

Staffieri, Francesco; Stripoli, Tania; Monte, Valentina De; Crovace, Antonio; Sacchi, Marianna; Michele, Michele De; Trerotoli, Paolo; Terragni, Pierpaolo; Ranieri, V. Marco; Grasso, Salvatore

doi:10.1097/ccm.0b013e31824e1b65

Cited by 53 publications

(39 citation statements)

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“…Nevertheless, at least to our knowledge, in all the previous clinical studies, after the correct balloon position was checked at baseline, the esophageal balloon position was not changed thereafter because it was assumed that the application of RM and/or different PEEP levels did not influence P ES measurements. 9,20,[27][28][29][30][31]38 Furthermore, in our study, according to the "Gattinoni method," 9,29 we did not trust on the absolute P ES values, but instead, we used the positive tidal P ES excursions to calculate E CW and subsequently calculated P L based on the ration between E CW and E L . 29 Furthermore, for the same reason, our P L measurement is likely less prone than the absolute P ES to be influenced by different degrees of lung atelectasis; (4) in our study, we applied a standardized open lung strategy consisting in an RM followed by PEEP 5 cm H 2 O.…”

Section: Discussionmentioning

confidence: 99%

“…Alveolar recruitment was measured though a physiologic method originally described by Ranieri et al, 36 subsequently applied in several physiologic clinical studies 18,28,34,[37][38][39] and recently validated by Dellamonica et al 40 In brief, for each experimental condition, we first measured the quasistatic volume-pressure curves of the respiratory system through the low-flow inflation technique as originally described by Lu et al 41 and subsequently measured the delta end-expiratory PERIOPERATIVE MEDICINE lung volume as the difference between the end-expiratory lung volume during mechanical ventilation and the elastic equilibrium volume of the respiratory system at zero endexpiratory pressure, or relaxation volume (V r ) or functional residual capacity. The delta end-expiratory lung volume was measured by disconnecting the patient from the ventilator circuit distally from the pneumotachograph and allowing a prolonged expiration (15-20 s; fig.…”

Section: Measurementsmentioning

confidence: 99%

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Effects of Recruitment Maneuver and Positive End-expiratory Pressure on Respiratory Mechanics and Transpulmonary Pressure during Laparoscopic Surgery

et al. 2013

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Background: The authors tested the hypothesis that during laparoscopic surgery, Trendelenburg position and pneumoperitoneum may worsen chest wall elastance, concomitantly decreasing transpulmonary pressure, and that a protective ventilator strategy applied after pneumoperitoneum induction, by increasing transpulmonary pressure, would result in alveolar recruitment and improvement in respiratory mechanics and gas exchange. Methods: In 29 consecutive patients, a recruiting maneuver followed by positive end-expiratory pressure 5 cm H 2 O maintained until the end of surgery was applied after pneumoperitoneum induction. Respiratory mechanics, gas exchange, blood pressure, and cardiac index were measured before (T BSL ) and after pneumoperitoneum with zero positive end-expiratory pressure (T preOLS ), after recruitment with positive end-expiratory pressure (T postOLS ), and after peritoneum desufflation with positive end-expiratory pressure (T end ). Results: Esophageal pressure was used for partitioning respiratory mechanics between lung and chest wall (data are mean ± SD): on T preOLS , chest wall elastance (E cw ) and elastance of the lung (E L ) increased (8.2 ± 0.9 vs. 6.2 ± 1.2 cm H 2 O/L, respectively, on T BSL ; P = 0.00016; and 11.69 ± 1.68 vs. 9.61 ± 1.52 cm H 2 O/L on T BSL ; P = 0.0007). On T postOLS , both chest wall elastance and E L decreased (5.2 ± 1.2 and 8.62 ± 1.03 cm H 2 O/L, respectively; P = 0.00015 vs. T preOLS ), and PaO 2 /inspiratory oxygen fraction improved (491 ± 107 vs. 425 ± 97 on T preOLS; P = 0.008) remaining stable thereafter. Recruited volume (the difference in lung volume for the same static airway pressure) was 194 ± 80 ml. Pplat RS remained stable while inspiratory transpulmonary pressure increased (11.65 + 1.37 cm H 2 O vs. 9.21 + 2.03 on T preOLS ; P = 0.007). All respiratory mechanics parameters remained stable after abdominal desufflation. Hemodynamic parameters remained stable throughout the study. Conclusions:In patients submitted to laparoscopic surgery in Trendelenburg position, an open lung strategy applied after pneumoperitoneum induction increased transpulmonary pressure and led to alveolar recruitment and improvement of E cw and gas exchange. LAPAROSCOPY is a well-established procedure for pelvic gynecologic surgery often performed in Trendelenburg position.1,2 To facilitate laparoscopic surgical manipulation, a pneumoperitoneum is usually induced through carbon dioxide inflation. Both the increase in abdominal pressure as a result of carbon dioxide inflation and the head down body position have been shown to impair the respiratory function during the procedure, mainly inducing atelectasis formation in the dependent lung regions. 1,[3][4][5][6] The resulting decrease in functional residual capacity poses Address correspondence to Dr. Cinnella: Departmentt of Anesthesia and Intensive Care, Policlinico 'Riuniti' -University of Foggia, Viale Pinto 1 -71100 Foggia, Italy. g.cinnella@unifg.it. Information on purchasing reprints may be found at www.anesthesiology.org...

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Section: Discussionmentioning

confidence: 99%

Section: Measurementsmentioning

confidence: 99%

Effects of Recruitment Maneuver and Positive End-expiratory Pressure on Respiratory Mechanics and Transpulmonary Pressure during Laparoscopic Surgery

et al. 2013

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“…Short-term anaesthesia of domestic pigs is often required in biomedical research for minor surgical or diagnostic procedures (Hastings et al, 1982;Swindle et al, 1994;Nunes et al, 2007;Grasso et al, 2009;Staffieri et al, 2012;Jordan et al, 2014). The ideal anaesthetic protocol in pigs should provide fast and reliable immobilisation, minimal cardiovascular and respiratory depression, and adequate analgesia and muscle relaxation.…”

Section: Introductionmentioning

confidence: 99%

Comparison of ketamine–dexmedetomidine–methadone and tiletamine–zolazepam–methadone combinations for short-term anaesthesia in domestic pigs

Monte

Staffieri

Meo

et al. 2015

The Veterinary Journal

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Cardiorespiratory effects, quality of induction, depth of anaesthesia and quality of recovery were compared in pigs anaesthetised with 8 mg/kg ketamine, 20 µg/kg dexmedetomidine and 0.2 mg/kg methadone (KDM, n = 18) or 8 mg/kg tiletamine-zolazepam and 0.2 mg/kg methadone (TZM, n = 9). Anaesthesia with KDM was partially reversed in nine animals with 0.2 mg/kg atipamezole (KDMat). Sedation was observed earlier in the TZM group (47.2 ± 25.3 s) than the KDM group (91.5 ± 37.4 s). Sternal and lateral recumbency were achieved earlier in the TZM group (76.3 ± 36.5 s and 132.1 ± 30.5 s, respectively) than in the KDM group (149.1 ± 58.7 s and 249.2 ± 84.0 s, respectively). PaO2, SaO2 and PaO2:FiO2 were lower in the TZM group (68.7 ± 4.1 mmHg, 93.4 ± 1.4% and 327.2 ± 19.9 mmHg, respectively) than in the KDM group (80.4 ± 5.9 mmHg, 95.7 ± 1.0% and 380.4 ± 25.6 mmHg, respectively). Fshunt and P(A-a)O2 were higher in the TZM group (24.0 ± 11.8% and 31.4 ± 3.8 mmHg, respectively) than in the KDM group (13.4 ± 3.2% and 20.7 ± 7.4 mmHg, respectively). Times from drug injection to first head movements, sternal recumbency and standing/walking were significantly shorter in the KDM group (45.1 ± 10.5, 48.4 ± 12.6 and 54.4 ± 17.8 min, respectively) than in the TZM group (57.8 ± 11.4, 93.1 ± 14.2 and 165.7 ± 56.6 min, respectively). The median recovery score was higher in the TZM group than in the KDMnoat and KDMat subgroups. Both drug combinations provided adequate anaesthesia for minor procedures lasting about 30 min, but TZM was associated with a poor recovery and oxygenation.

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“…The elastance-derived P, is then defined to be a fraction of P equal pi ao t o the ratio of chest wall elastance to total respiratory system elastance (P^, = P^^ x E^JE^¡) (9). Setting PEEP based on each of these methods has shown promise in small studies (10,11). Although these two methods each attempt to estimate P j, they are based on different physiological ideas and formulas and cannot, in general, yield the same value.…”

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confidence: 98%

Pleural Pressure and Optimal Positive End-Expiratory Pressure Based on Esophageal Pressure Versus Chest Wall Elastance

Gulati

Novero

Loring

et al. 2013

Critical Care Medicine

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Esophageal pressure and chest wall elastance-based methods for estimating pleural pressure do not yield similar results. The strategies of targeting an end-expiratory esophageal pressure-based transpulmonary pressure of 0 cm H2O and targeting an end-inspiratory elastance-based transpulmonary pressure of 26 cm H2O cannot be considered interchangeable. Finally, chest wall and respiratory system elastances may vary unpredictably with changes in positive end-expiratory pressure.

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Physiological effects of an open lung ventilatory strategy titrated on elastance-derived end-inspiratory transpulmonary pressure

Abstract: In this model, the end-inspiratory transpulmonary open lung approach minimized the impact of chest wall stiffening on alveolar recruitment without causing hemodynamic impairment.

Cited by 53 publications

References 54 publications

Effects of Recruitment Maneuver and Positive End-expiratory Pressure on Respiratory Mechanics and Transpulmonary Pressure during Laparoscopic Surgery

Effects of Recruitment Maneuver and Positive End-expiratory Pressure on Respiratory Mechanics and Transpulmonary Pressure during Laparoscopic Surgery

Comparison of ketamine–dexmedetomidine–methadone and tiletamine–zolazepam–methadone combinations for short-term anaesthesia in domestic pigs

Pleural Pressure and Optimal Positive End-Expiratory Pressure Based on Esophageal Pressure Versus Chest Wall Elastance

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