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Derecruitment of the lung induced by stepwise lowering of positive end-expiratory pressure in patients with adult respiratory distress syndrome

Published online by Cambridge University Press:  11 July 2005

E. De Robertis ,
G. Servillo ,
M. Pezza ,
D. Viscidi  and
R. Tufano
E. De Robertis
Affiliation:
University of Naples ‘Federico II’, Department of Anaesthesia and Intensive Care, Naples, Italy
G. Servillo
Affiliation:
University of Naples ‘Federico II’, Department of Anaesthesia and Intensive Care, Naples, Italy
M. Pezza
Affiliation:
University of Naples ‘Federico II’, Department of Anaesthesia and Intensive Care, Naples, Italy
D. Viscidi
Affiliation:
University of Naples ‘Federico II’, Department of Anaesthesia and Intensive Care, Naples, Italy
R. Tufano
Affiliation:
University of Naples ‘Federico II’, Department of Anaesthesia and Intensive Care, Naples, Italy
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Extract

Summary

Background and objective: It has recently been suggested that recruitment proceeds far above the lower inflection point of the elastic pressure–volume (Pel/V) curve of the respiratory system. Accordingly, the value of the lower inflection point as a guide to set the positive end-expiratory pressure (PEEP) has been challenged. Our aim was to evaluate the derecruitment induced by stepwise decreasing PEEP levels.

Methods: Seven consecutive sedated and paralysed patients with acute respiratory distress syndrome were studied. Multiple Pel/V curves of the respiratory system were recorded at PEEP levels progressively decreasing in steps of 3.75 cmH2O from +15 to zero according to the principles of the low flow inflation method.

Results: Multiple Pel/V curves shifted towards lower volumes at decreasing PEEP. Dynamic compliance was higher for Pel/V curves recorded from lower PEEP levels. A high correlation (r = 0.99) was found between dynamic compliance and PEEP. The lower inflection point was on average 9.2 cmH2O. However, the transition between the lower segment and the linear part of the Pel/V curve was in general smooth to the eye. The upper inflection point was on average 23.8 cmH2O. A high correlation (r = 0.98) between the upper inflection point and PEEP was found.

Conclusions: The lower inflection point is a poor indicator of alveolar closure. The evaluation of derecruitment induced by a stepwise reduction in PEEP seems to be more useful than individual titration of PEEP and tidal volume in patients with adult respiratory distress syndrome.

Keywords

BIOMECHANICS, elasticity, complianceRESPIRATION, respiratory mechanicsRESPIRATORY THERAPY, respiration, artificial
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 20 , Issue 10 , November 2003 , pp. 794 - 799
Copyright
© 2003 European Society of Anaesthesiology

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References

Matamis D, Lemaire F, Harf A, Brun-Buisson C, Ansquer JC, Atlan G. Total respiratory pressure–volume curves in the adult respiratory distress syndrome. Chest 1984; 86: 58–66.Google Scholar
Ranieri VM, Giuliani R, Fiore T, Dambrosio M, Milic-Emili J. Volume-pressure curve of the respiratory system predicts effects of PEEP in ARDS: ‘occlusion’ versus ‘constant flow’ technique. Am J Respir Crit Care Med 1994; 149: 19–27.Google Scholar
Roupie E, Dambrosio M, Servillo G, et al. Titration of tidal volume and induced hypercapnia in acute respiratory distress syndrome. Am J Respir Crit Care Med 1995; 152: 121–128.Google Scholar
Servillo G, Svantesson C, Beydon L, et al. Pressure–volume curves in acute respiratory failure. Automated low flow inflation versus occlusion. Am J Respir Crit Care Med 1997; 155: 1629–1636.Google Scholar
Servillo G, De Robertis E, Coppola M, Blasi F, Rossano F, Tufano R. Application of a computerised method to measure static pressure volume curve in acute respiratory distress syndrome. Intens Care Med 2000; 26: 11–14.Google Scholar
Lemaire F. ARDS and PV curves: the inseparable duet? Intens Care Med 2000; 26: 1–2.Google Scholar
Jonson B, Svantesson C. Elastic pressure–volume curve: what information do they convey? Thorax 1999; 54: 82–87.Google Scholar
Hickling KG. The pressure–volume curve is greatly modified by recruitment. A mathematical model of ARDS lungs. Am J Respir Crit Care Med 1998; 158: 194–202.Google Scholar
Liu JM, De Robertis E, Blomquist S, Dahm PL, Svantesson C, Jonson B. Elastic pressure–volume curves of the respiratory system reveal a high tendency to lung collapse in young pigs. Intens Care Med 1999; 25: 1140–1146.Google Scholar
De Robertis E, Liu JM, Blomquist S, Dahm PL, Thorne J, Jonson B. Elastic properties of the lung and chest wall in young and adult healthy pigs. Eur Respir J 2001; 17: 703–711.Google Scholar
Jonson B, Richard JC, Straus C, Mancebo J, Lemaire F, Brochard L. Pressure–volume curves in acute lung injury. Evidence of recruitment above the lower inflection point. Am J Respir Crit Care Med 1999; 159: 1172–1178.Google Scholar
Svantesson C, Drefeldt B, Sigurdsson S, Larsson A, Brochard L, Jonson B. A single computer-controlled mechanical insufflation allows determination of the pressure–volume relationship of the respiratory system. J Clin Monit 1999; 15: 9–16.Google Scholar
Sigurdson S, Svantesson C, Larsson A, Jonson B. Elastic pressure–volume curves indicate derecruitment after a single deep expiration in anaesthetised and muscle-relaxed healthy man. Acta Anaesthesiol Scand 2000; 44: 980–984.Google Scholar
Bernard GR, Artigas A, Brigham KL, et al. The American–European consensus conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994; 149: 818–824.Google Scholar
Murray JF, Matthay MA, Luce JM, Flick MR. An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis 1988; 138: 720–723.Google Scholar
Servillo G, Coppola M, Blasi F, Tufano R. The measurement of the pressure–volume curves with computerized methods. Minerva Anesthesiol 2000; 66: 381–385.Google Scholar
Svantesson C, Sigurdsson S, Larsson A, Jonson B. Effects of recruitment of collapsed lung units on the elastic pressure–volume relationship in anaesthetised healthy adults. Acta Anaesthesiol Scand 1998; 42: 1149–1156.Google Scholar
Gattinoni L, Pesenti A, Bombino M, et al. Relationships between lung computed tomographic density, gas exchange, and PEEP in acute respiratory failure. Anesthesiology 1988; 69: 824–832.Google Scholar
Maggiore SM, Jonson B, Richard JC, Jaber S, Lemaire F, Brochard L. Alveolar derecruitment at decremental positive end-expiratory pressure levels in acute lung injury. Comparison with the lower inflection point, oxygenation and compliance. Am J Respir Crit Care Med 2001; 164: 795–801.Google Scholar
Vieira SR, Puybasset L, Lu Q, et al. A scanographic assessment of pulmonary morphology in acute lung injury. Significance of the lower inflection point detected on the lung pressure–volume curve. Am J Respir Crit Care Med 1999; 159: 1612–1623.Google Scholar
Lachmann B. Open up the lung and keep the lung open. Intens Care Med 1992; 18: 319–321.Google Scholar
Mergoni M, Martelli A, Volpi A, Primavera S, Zuccoli P, Rossi A. Impact of positive end-expiratory pressure on chest-wall and lung pressure–volume curve in acute respiratory failure. Am J Respir Crit Care Med 1997; 156: 846–854.Google Scholar
Svantesson C, Sigurdsson S, Larson A, Jonson B. The contribution of the chest wall to the elastic pressure–volume curve of the total respiratory system. Intens Care Med 1998; 24: S95.Google Scholar
Ranieri VM, Brienza N, Santostasi S, et al. Impairment of lung and chest wall mechanics in patients with acute respiratory distress syndrome: role of abdominal distension. Am J Respir Crit Care Med 1997; 156: 1082–1091.Google Scholar
Richard JC, Maggiore SM, Jonson B, Mancebo J, Lemaire F, Brochard L. Influence of tidal volume on alveolar recruitment. Respective role of PEEP and recruitment maneuvre. Am J Respir Crit Care Med 2001; 163: 1609–1613.Google Scholar
Servillo G, De Robertis E, Maggiore S, Lemaire F, Brochard L, Tufano R. The upper inflection point of the pressure–volume curve. Influence of methodology and of different modes of ventilation. Intens Care Med 2002; 28: 842–849.Google Scholar