Ventilation with end-expiratory pressure in acute lung disease

Falke, K. J.; Pontoppidan, Henning; Kumar, Anil; Leith, David; Geffin, Bennie; Laver, Myron B.

doi:10.1172/jci107042

Cited by 374 publications

(125 citation statements)

References 20 publications

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“…This is consistent with the findings in normal subjects [32] and in ARDS patients [22,23,28,29] obtained over a larger PEEP range, but contrasts with the results of FALKE et al [25], who found a decrease in static elastance (Est) with PEEP of 5 cmH 2 O. The lack of Ers,st changes with PEEP in the present patients is not surprising because, like normal subjects, they did not exhibit an inflection point on the static inflation V-P curve (figs.…”

Section: Elastance and Resistancesupporting

confidence: 90%

“…1 and 2). According to some authors [25][26][27], in ARDS patients without AIDS and PCP the inflection point is a common occurrence, though this might not be particularly frequent according to other studies [22,[28][29][30]. It has been suggested that the inflection is present in the earliest stage of ARDS, whereas later on, probably as a result of oedema resolution, the inflection disappears with or without increases or decreases in elastance, probably depending on the pattern of fibrosis development [26].…”

Section: Static Inflation V-p Curvementioning

confidence: 99%

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Lung and chest wall mechanics in patients with acquired immunodeficiency syndrome and severe Pneumocystis carinii pneumonia

et al. 1997

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Lung and chest wall mechanics in patients with acquired immunodeficiency syndrome and severe Pneumocystis carinii pneumonia. E. D 'Angelo, E. Calderini, F.M. Robatto, P. Puccio, J. Milic-Emili. ERS Journals Ltd 1997. ABSTRACT: The aim of this study was to assess the mechanical characteristics of the respiratory system in patients with acquired immune deficiency syndrome (AIDS) and acute respiratory distress syndrome (ARDS) caused by Pneumocystis carinii pneumonia (PCP).In 12 mechanically ventilated patients, total respiratory system mechanics was assessed using the technique of rapid airway occlusion during constant flow inflation, and was partitioned into lung and chest wall components using the oesophageal balloon technique. We measured interrupter resistance (Rint), which mainly reflects airway resistance, additional resistance (∆R) due to viscoelastic behaviour and time constant inequalities, and static elastance (Est). In addition, the static inflation volume-pressure (V-P) curve was assessed. In eight patients, computed tomography scans were performed within 2 days of the assessment of respiratory mechanics.Compared to values reported in the literature for normal subjects, Est and ∆R were markedly increased in AIDS patients with PCP, whilst Rint exhibited a relatively smaller increase. These changes, which involved only the lung and airways, were mainly due to the reduction of ventilated lung units, but additional factors were involved to cause independent modifications of lung stiffness, airway calibre, and viscoelastic properties. The changes in Rint, ∆R, and Est were similar to those observed in other studies on patients with ARDS of different aetiologies. At variance with common observations in the latter patients, none of the AIDS patients with PCP exhibited an inflection point on the static inflation V-P curve, suggesting little or no alveolar recruitment during lung inflation. This finding could be related to the distinctive histopathology of Pneumocystis carinii pneumonia. Indeed, computed tomography revealed homogeneous diffuse interstitial and alveolar infiltration rather than the dense, dependent opacities observed in other studies on acute respiratory distress syndrome of different aetiologies. Eur Respir J 1997; 10: 2343-2350 Pneumocystis carinii pneumonia (PCP) is the most frequent severe opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS). It is held responsible for up to 85% of episodes of acute respiratory failure that occur in AIDS [1] and 80% of emergency admissions to intensive care units [2,3], with a reported mortality rate of 75-100% for patients requiring mechanical ventilation [4]. In a recent consensus conference [5], PCP was included, though not by unanimous decision, among the causes of acute respiratory distress syndrome (ARDS), once the following criteria are met: acute onset; arterial oxygen tension (Pa,O 2 )/inspiratory oxygen fraction (FI,O 2 ) <27 kPa (200 mmHg); bilateral infiltrates on chest radiographs; and no evidence of left atrial hyp...

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Section: Elastance and Resistancesupporting

confidence: 90%

Section: Static Inflation V-p Curvementioning

confidence: 99%

Lung and chest wall mechanics in patients with acquired immunodeficiency syndrome and severe Pneumocystis carinii pneumonia

et al. 1997

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“…However, life-threatening complications such as pneumothorax occurred and mortality was high [65]. With the introduction of positive end-expiratory pressure (PEEP), oxygen uptake improved and the incidence of pneumothoraces in ARDS patients was reduced dramatically [66][67][68]. In addition, Hickling et al observed that ventilation with a lower Vt (i.e.…”

Section: Mechanical Ventilationmentioning

confidence: 99%

Pediatric acute lung injury

Dahlem

Aalderen

Bos

2007

Paediatric Respiratory Reviews

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“…The adult respiratory distress syndrome, later called acute respiratory distress syndrome (ARDS), became the prototype pathology accompanying the development of intensive care medicine (5) and PEEP was one of the most widely used therapeutic approaches. The first studies on mechanisms of PEEP during ARDS were performed by Falke and colleagues at the Massachusetts General Hospital (6), while the most popular clinical approach for PEEP setting was proposed by Suter as a function of oxygen transport and respiratory mechanics (7). In the meantime, Kirby and colleagues, from Miami, proposed the use of a "super PEEP" , that is PEEP up to 25 cmH 2 O, somehow forerunner of the "open lung approach" (8).…”

Section: Introductionmentioning

confidence: 99%

Positive end-expiratory pressure: how to set it at the individual level

Gattinoni¹,

Collino²,

Maiolo³

et al. 2017

Ann. Transl. Med.

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Abstract:The positive end-expiratory pressure (PEEP), since its introduction in the treatment of acute respiratory failure, up to the 1980s was uniquely aimed to provide a viable oxygenation. Since the first application, a large debate about the criteria for selecting the PEEP levels arose within the scientific community. Lung mechanics, oxygen transport, venous admixture thresholds were all proposed, leading to PEEP recommendations from 5 up to 25 cmH 2 O. Throughout this period, the main concern was the hemodynamics. This paradigm changed during the 1980s after the wide acceptance of atelectrauma as one of the leading causes of ventilator induced lung injury. Accordingly, the PEEP aim shifted from oxygenation to lung protection. In this framework, the prevention of lung opening and closing became an almost unquestioned dogma. Consequently, as PEEP keeps open the pulmonary units opened during the previous inspiratory phase, new methods were designed to identify the 'optimal' PEEP during the expiratory phase.The open lung approach requires that every collapsed unit potentially openable is opened and maintained open. The methods to assess the recruitment are based on imaging (computed tomography, electric impedance tomography, ultrasound) or mechanically-driven gas exchange modifications. All the latest assume that whatever change in respiratory system compliance is due to changes in lung compliance, which in turn is uniquely function of the recruitment. Comparative studies, however, showed that the only possible approach to measure the amount of collapsed tissue regaining inflation is the CT scan. In fact, all the other methods estimate as recruitment the gas entry in pulmonary units already open at lower PEEP, but increasing their compliance at higher PEEP. Since higher PEEP is usually more indicated (also for oxygenation) when the recruitability is higher, as occurs with increasing severity, a meaningful PEEP selection requires the assessment of recruitment. The Berlin definition may help in this assessment.

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Ventilation with end-expiratory pressure in acute lung disease

Abstract: Pao, and compliance is recruitment of gas exchange airspaces and prevention of terminal airway closure.Address reprint requests to Dr. Pontoppidan.

Cited by 374 publications

References 20 publications

Lung and chest wall mechanics in patients with acquired immunodeficiency syndrome and severe Pneumocystis carinii pneumonia

Lung and chest wall mechanics in patients with acquired immunodeficiency syndrome and severe Pneumocystis carinii pneumonia

Pediatric acute lung injury

Positive end-expiratory pressure: how to set it at the individual level

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