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Critical Care
Published in: Critical Care 1/2015

Open Access 01-12-2015 | Research

Adjusting tidal volume to stress index in an open lung condition optimizes ventilation and prevents overdistension in an experimental model of lung injury and reduced chest wall compliance

Authors: Carlos Ferrando, Fernando Suárez-Sipmann, Andrea Gutierrez, Gerardo Tusman, Jose Carbonell, Marisa García, Laura Piqueras, Desamparados Compañ, Susanie Flores, Marina Soro, Alicia Llombart, Francisco Javier Belda

Published in: Critical Care | Issue 1/2015

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Abstract

Introduction

The stress index (SI), a parameter derived from the shape of the pressure-time curve, can identify injurious mechanical ventilation. We tested the hypothesis that adjusting tidal volume (VT) to a non-injurious SI in an open lung condition avoids hypoventilation while preventing overdistension in an experimental model of combined lung injury and low chest-wall compliance (Ccw).

Methods

Lung injury was induced by repeated lung lavages using warm saline solution, and Ccw was reduced by controlled intra-abdominal air-insufflation in 22 anesthetized, paralyzed and mechanically ventilated pigs. After injury animals were recruited and submitted to a positive end-expiratory pressure (PEEP) titration trial to find the PEEP level resulting in maximum compliance. During a subsequent four hours of mechanical ventilation, VT was adjusted to keep a plateau pressure (Pplat) of 30 cmH2O (Pplat-group, n = 11) or to a SI between 0.95 and 1.05 (SI-group, n = 11). Respiratory rate was adjusted to maintain a ‘normal’ PaCO2 (35 to 65 mmHg). SI, lung mechanics, arterial-blood gases haemodynamics pro-inflammatory cytokines and histopathology were analyzed. In addition Computed Tomography (CT) data were acquired at end expiration and end inspiration in six animals.

Results

PaCO2 was significantly higher in the Pplat-group (82 versus 53 mmHg, P = 0.01), with a resulting lower pH (7.19 versus 7.34, P = 0.01). We observed significant differences in VT (7.3 versus 5.4 mlKg−1, P = 0.002) and Pplat values (30 versus 35 cmH2O, P = 0.001) between the Pplat-group and SI-group respectively. SI (1.03 versus 0.99, P = 0.42) and end-inspiratory transpulmonary pressure (PTP) (17 versus 18 cmH2O, P = 0.42) were similar in the Pplat- and SI-groups respectively, without differences in overinflated lung areas at end- inspiration in both groups. Cytokines and histopathology showed no differences.

Conclusions

Setting tidal volume to a non-injurious stress index in an open lung condition improves alveolar ventilation and prevents overdistension without increasing lung injury. This is in comparison with limited Pplat protective ventilation in a model of lung injury with low chest-wall compliance.
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Literature
1.
Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342:1301–8.
2.
Amato M, Barbas C, Medeiros D, Magaldi R, Schettino G, Lorenzi-Filho G, et al. Effect of a protective ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1999;338:347–54.
3.
Staffieri F, Stripoli T, De Monte V, Crovace A, Sacchi M, De Michele M, et al. Physiological effects of an open lung ventilatory strategy titrated on elastance-derived end-inspiratory transpulmonary pressure: study in a pig model. Crit Care Med. 2012;40:2124–31.PubMed
4.
Regli A, Mahendran R, Fysh ET, Roberts B, Noffsinger B, De Keulenaer BL, et al. Matching positive end-expiratory pressure to intra-abdominal pressure improves oxygenation in a porcine sick lung model of intra-abdominal hypertension. Crit Care. 2012;16:R208.PubMedPubMedCentral
5.
Formenti P, Graf J, Cortes GA, Faltesek K, Gard K, Adams AB, et al. Experimental intra-abdominal hypertension attenuates the benefit of positive end-expiratory pressure in ventilating effusion-compressed lungs. Crit Care Med. 2012;40:2176–81.PubMed
6.
Grasso S, Terragni P, Mascia L, Fanelli V, Quintel M, Herrmann P, et al. Airway pressure-time curve profile (stress index) detects tidal recruitment/hyperinflation in experimental acute lung injury. Crit Care Med. 2004;32:1018–27.PubMed
7.
Terragni P, Filippini C, Slutsky A, Birocco A, Tenaglia T, Grasso S, et al. Accuracy of plateau pressure and stress index to indentify injurious ventilation in patients with acute respiratory distress syndrome. Anesthesiology. 2013;119:880–9.PubMed
8.
Ranieri VM, Zhang H, Mascia L, Aubin M, Lin C, Mullen J, et al. Pressure-time curve predicts minimally injurious ventilatory strategy in an isolated rat lung model. Anesthesiology. 2000;93:1320–8.PubMed
9.
Huang Y, Yang Y, Chen Q, Liu S, Liu L, Pan C, et al. Pulmonary acute distress syndrome: positive end-expiratory pressure titration needs stress index. J Surg Res. 2013;185:347–52.PubMed
10.
Krebs J, Pelosi P, Tsagogiorgas C, Alb M, Luecke T. Effects of positive end-expiratory pressure on respiratory function and hemodynamics in patients with acute respiratory failure with and without intra-abdominal hypertension: a pilot study. Crit Care. 2009;13:R160.PubMedPubMedCentral
11.
Karmrodt J, Bletz C, Yuan S, David M, Heussel C, Markstaller K. Quantification of atelectatic lung volumes in two different porcine models of ARDS. Br J Anaesth. 2006;97:883–95.PubMed
12.
Spragg R, Lewis J, Wurst W, Häfner D, Baughman R, Wewers M, et al. Treatment of acute respiratory distress syndrome with recombinant surfactant protein C surfactant. Am J Respir Crit Care Med. 2003;167:1562–6.PubMed
13.
Anzueto A, Baughman R, Guntupalli K, Weg J, Wiedemann H, Raventós A, et al. Aerosolized surfactant in adults with sepsis-induced respiratory distress syndrome. N Engl J Med. 1996;334:1417–21.PubMed
14.
Matute-Bello G, Frevert G, Martin T. Animal models of acute lung injury. Am J Physiol Lung Cell Mol Physiol. 2008;295:L379–99.PubMedPubMedCentral
15.
Bolbner M, Bogdanski R, Kochs E, Henke J, Findeis A, Jelen-Heselborn S. Effects of intra-abdominally insufflated carbon dioxide and elevated intra-abdominal pressure on splanchnic circulation: an experimental study in pigs. Anesthesiology. 1998;89:475–82.
16.
Malbrain ML, Cheatmam ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J, et al. Results from the international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome I. Definitions. Intensive Care Med. 2006;32:1722–32.PubMed
17.
Baydur A, Behrakis PK, Zin WA, Jaeger M, Milic-Emili J. A simple method for assessing the validity of the esophageal balloon technique. Am Rev Respir Dis. 1982;126:788–91.PubMed
18.
Bardoczky GI, d’Hollander AA, Cappello M, Yernault JC. Interrupted expiratory flow on automatically constructed flow-volume curves may determine the presence of intrinsic positive end-expiratory pressure during one-lung ventilation. Anesth Analg. 1998;86:880–4.PubMed
19.
Ferrando C, Aguilar G, Piqueras L, Soro M, Moreno J, Belda FJ. Sevoflurane, but not propofol, reduces the lung inflammatory response and improves oxygenation in an acute respiratory distress syndrome model: a randomised laboratory study. Eur J Anaesthesiol. 2013;30:455–63.PubMed
20.
da Silva Ramos FJ, de Oliveira EM, Park M, Schettino G, Azevedo L. Heart-lung interactions with different ventilatory settings during acute lung injury and hypovolaemia: an experimental study. Br J Anaesth. 2011;106:394–402.PubMed
21.
Suarez-Sipmann F, Böhm S, Tusman G, Pesch T, Thamm O, Reissmann H, et al. Use of dynamic compliance for open lung positive end-expiratory pressure titration in an experimental study. Crit Care Med. 2007;35:214–21.PubMed
22.
Vieira SR, Puybasset L, Richecoeur J, Lu Q, Cluzel P, Gusman PB, et al. A lung computed tomographic assessment of positive end-expiratory pressure-induced lung overdistension. Am J Respir Crit Care Med. 1998;158:1571–7.PubMed
23.
Chiumelo D, Carlesso E, Cadringher P, Caironi P, Valenza F, Polli F, et al. Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome. Am J Respir Crit Care Med. 2008;178:346–55.
24.
Pelosi P, Luecke T, Rocco PR. Chest wall mechanics and abdominal pressure during general anaesthesia in normal and obese individuals and in acute lung injury. Curr Opin Crit Care. 2011;17:72–9.PubMed
25.
Petrucci N, Lacovelli W. Ventilation with smaller tidal volumes: a quantitative systematic review of randomized controlled trials. Anesth Analg. 2004;99:193–200.PubMed
26.
Talmor D, Sarge T, Malhotra A, O’Donnell CR, Ritz R, Lisbon A, et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med. 2008;359:2095–104.PubMedPubMedCentral
27.
Cortes-Puentes GA, Gard KE, Adams AB, Faltesek KA, Anderson CP, Dries DJ, et al. Value and limitations of transpulmonary pressure calculations during intra-abdominal hypertension. Crit Care Med. 2013;41:1870–7.PubMed
28.
Akoumianaki E, Maggiore SM, Valenza F, Bellani G, Jubran A, Loring SH, et al. The application of esophageal pressure measurement in patients with respiratory failure. Am J Respir Crit Care Med. 2014;189:520–31.PubMed
29.
Formenti P, Graf J, Santos A, Gard KE, Faltesek K, Adams AB, et al. Non-pulmonary factors strongly influence the stress index. Intensive Care Med. 2011;34:594–600.
30.
Carvalho A, Spieth P, Pelosi P, Vidal Melo M, Koch T, Jandre F, et al. Ability of dynamic airway pressure profile and elastance for positive end-expiratory pressure titration. Intensive Care Med. 2008;34:2291–9.PubMedPubMedCentral
31.
Bellardine Black CL, Hoffman AM, Tsai LW, Ingenito EP, Suki B, Kacka DW, et al. Relationship between dynamic respiratory mechanics and disease heterogenicity in sheep lavage injury. Crit Care Med. 2007;35:870–8.PubMed
32.
Oeckler RA, Hubmayr RD. Ventilator associated lung injury: a search for better therapeutic targets. Eur Respir J. 2007;30:1216–26.PubMed
33.
Villar J, Herrera-Abreu MT, Valladares F, Muros M, Pérez-Méndez L, Flores C, et al. Experimental ventilator induced lung injury: exacerbation by positive end-expiratory pressure. Anesthesiology. 2009;110:1341–7.PubMed
34.
Belperio JA, Keane MP, Lynch 3rd JP, Strieter R. The role of cytokines during the pathogenesis of ventilator-associated and ventilator induced lung injury. Semin Respir Crit Care Med. 2006;27:350–64.PubMed
35.
Wolthuis EK, Vlaar A, Choi G, Roelofs J, Juffermans NP, Schultz MJ. Mechanical ventilation using non-injurious ventilation setting causes lung injury in the absence of pre-existing lung injury in healthy mice. Crit Care. 2009;13:R1.PubMedPubMedCentral
36.
Wolthuis EK, Choi G, Dessing MC, Bresser P, Lutter R, Dzoljic M, et al. Mechanical ventilation with lower tidal volumes and positive end-expiratory pressure prevents pulmonary inflammation in patients without pre-existing lung injury. Anesthesiology. 2008;108:46–54.PubMed
37.
Santos C, Moraes L, Souza R, DoSantos C, Dutra J, Marcos M, et al. The biological effects of higher and lower positive end-expiratory pressure in pulmonary and extrapulmonary acute lung injury with intra-abdominal hypertension. Crit Care. 2014;18:R121.PubMedPubMedCentral
38.
Ranieri M, Suter P, Tortorella C, De Tullio R, Dayer J, Brienza A, et al. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial. JAMA. 1999;282:54–61.PubMed
39.
Kushimoto S, Taira Y, Kitazawa Y, Okuchi K, Sakamoto T, Ishikura H, et al. The PiCCO pulmonary edema study group. Crit Care. 2012;16:R232.PubMedPubMedCentral
40.
Su F, Nauyen N, Creteur J, Cai Y, Nagy N, Anh-Dung H, et al. Use of low tidal volume in septic shock may decrease severity of subsequent acute lung injury. Shock. 2004;22:145–50.PubMed
41.
Regli A, Hocking L, Musk G, Roberts B, Noffsinger B, Singh B, et al. Commonly applied positive end-expiratory pressures do not prevent functional residual capacity decline in the setting of intra-abdominal hypertension: a pig model. Crit Care. 2010;14:R128.PubMedPubMedCentral
42.
Quintel M, Pelosi P, Caironi P, Meinhardt JP, Luecke T, Herrmann P, et al. An increase of abdominal pressure increases pulmonary edema in oleic acid-induced lung injury. Am J Respir Crit Care Med. 2004;169:534–41.PubMed
43.
Rodriguez P, Bonelli I, Setten M, Attie S, Madorno M, Maskin L, et al. Transpulmonary pressure and gas exchange during decremental PEEP titration in pulmonary ARDS patients. Respir Care. 2013;58:754–63.PubMed
44.
Sturini E, Saporito A, Sugrue M, Parr MJ, Bishop G, Braschi A. Respiratory variation of intra-abdominal pressure: indirect indicator of abdominal compliance? Intensive Care Med. 2008;34:1632–7.PubMed
Metadata
Title
Adjusting tidal volume to stress index in an open lung condition optimizes ventilation and prevents overdistension in an experimental model of lung injury and reduced chest wall compliance
Authors
Carlos Ferrando
Fernando Suárez-Sipmann
Andrea Gutierrez
Gerardo Tusman
Jose Carbonell
Marisa García
Laura Piqueras
Desamparados Compañ
Susanie Flores
Marina Soro
Alicia Llombart
Francisco Javier Belda
Publication date
01-12-2015
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2015
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-014-0726-3

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