Top

Published in:

01-10-2005 | Original

Inspiratory vs. expiratory pressure-volume curves to set end-expiratory pressure in acute lung injury

Authors: Guillermo M. Albaiceta, Luis H. Luyando, Diego Parra, Rafael Menendez, Juan Calvo, Paula Rodríguez Pedreira, Francisco Taboada

Published in: Intensive Care Medicine | Issue 10/2005

Abstract

Objective

To study the effects of two levels of positive end-expiratory pressure (PEEP), 2 cmH₂O above the lower inflection point of the inspiratory limb and equal to the point of maximum curvature on the expiratory limb of the pressure-volume curve, in gas exchange, respiratory mechanics, and lung aeration.

Design and setting

Prospective clinical study in the intensive care unit and computed tomography ward of a university hospital.

Patients

Eight patients with early acute lung injury.

Interventions

Both limbs of the static pressure-volume curve were traced and inflection points calculated using a sigmoid model. During ventilation with a tidal volume of 6 ml/kg we sequentially applied a PEEP 2 cmH₂O above the inspiratory lower inflection point (15.5±3.1 cmH₂O) and a PEEP equal to the expiratory point of maximum curvature (23.5±4.1 cmH₂O).

Measurements and results

Arterial blood gases, respiratory system compliance and resistance and changes in lung aeration (measured on three computed tomography slices during end-expiratory and end-inspiratory pauses) were measured at each PEEP level. PEEP according to the expiratory point of maximum curvature was related to an improvement in oxygenation, increase in normally aerated, decrease in nonaerated lung volumes, and greater alveolar stability. There was also an increase in PaCO₂, airway pressures, and hyperaerated lung volume.

Conclusions

High PEEP levels according to the point of maximum curvature of the deflation limb of the pressure-volume curve have both benefits and drawbacks.

Brower RG, Rubenfeld GD (2003) Lung-protective ventilation strategies in acute lung injury. Crit Care Med 31:S312–S316CrossRefPubMed

Dreyfuss D, Saumon G (1998) Ventilator-induced lung injury: lessons from experimental studies. Am J Respir Crit Care Med 157:294–323PubMed

Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, Kairalla RA, Deheinzelin D, Munoz C, Oliveira R, Takagaki TY, Carvalho CR (1998) Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 338:347–354CrossRefPubMed

Acute Respiratory Distress Syndrome Network (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301–1308CrossRefPubMed

Putensen C, Baum M, Hormann C (1993) Selecting ventilator settings according to variables derived from the quasi-static pressure/volume relationship in patients with acute lung injury. Anesth Analg 77:436–447PubMed

Hickling KG (2001) Best compliance during a decremental, but not incremental, positive end- expiratory pressure trial is related to open-lung positive end- expiratory pressure: a mathematical model of acute respiratory distress syndrome lungs. Am J Respir Crit Care Med 163:69–78PubMed

Venegas JG, Harris RS, Simon BA (1998) A comprehensive equation for the pulmonary pressure-volume curve. J Appl Physiol 84:389–395PubMed

Albaiceta GM, Taboada F, Parra D, Luyando LH, Calvo J, Menendez R, Otero J (2004) Tomographic study of the inflection points of the pressure-volume curve in acute lung injury. Am J Respir Crit Care Med 170:1066–1072CrossRefPubMed

Goddon S, Fujino Y, Hromi JM, Kacmarek RM (2001) Optimal mean airway pressure during high-frequency oscillation: predicted by the pressure-volume curve. Anesthesiology 94:862–969CrossRefPubMed

10.

Albaiceta GM, Luyando LH, Parra D, Menendez R, Calvo J, Taboada F (2003) Inspiratory vs expiratory limb of the pressure-volume curve for the positive end-expiratory pressure setting in acute lung injury (abstract). Crit Care 8:25CrossRefPubMed

11.

Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, LeGall JR, Morris A, Spragg R (1994) Report of the American-European consensus conference on ARDS: definitions, mechanisms, relevant outcomes and clinical trial coordination. The Consensus Committee. Intensive Care Med 20:225–232CrossRefPubMed

12.

D’Angelo E, Calderini E, Tavola M, Bono D, Milic-Emili J (1992) Effect of PEEP on respiratory mechanics in anesthetized paralyzed humans. J Appl Physiol 73:1736–1742PubMed

13.

Gattinoni L, Pesenti A, Avalli L, Rossi F, Bombino M (1987) Pressure-volume curve of total respiratory system in acute respiratory failure. Computed tomographic scan study. Am Rev Respir Dis 136:730–736PubMed

14.

Gattinoni L, Pelosi P, Suter PM, Pedoto A, Vercesi P, Lissoni A (1998) Acute respiratory distress syndrome caused by pulmonary and extrapulmonary disease. Different syndromes? Am J Respir Crit Care Med 158:3–11PubMed

15.

Vieira SR, Nieszkowska A, Lu Q, Elman M, Sartorius A, Rouby JJ (2005) Low spatial resolution computed tomography underestimates lung overinflation resulting from positive pressure ventilation. Crit Care Med 33:741–749CrossRefPubMed

16.

Mehta S, Stewart TE, MacDonald R, Hallett D, Banayan D, Lapinsky S, Slutsky A (2003) Temporal change, reproducibility, and interobserver variability in pressure-volume curves in adults with acute lung injury and acute respiratory distress syndrome. Crit Care Med 31:2118–2125CrossRefPubMed

17.

Nishida T, Suchodolski K, Schettino GP, Sedeek K, Takeuch M, Kacmarek RM (2004) Peak volume history and peak pressure-volume curve pressures independently affect the shape of the pressure-volume curve of the respiratory system. Crit Care Med 32:1358–1364CrossRefPubMed

18.

Pereira C, Bohe J, Rosselli S, Combourieu E, Pommier C, Perdrix JP, Richard JC, Badet M, Gaillard S, Philit F, Guerin C (2003) Sigmoidal equation for lung and chest wall volume-pressure curves in acute respiratory failure. J Appl Physiol 95:2064–2071PubMed

19.

Rouby JJ, Puybasset L, Nieszkowska A, Lu Q (2003) Acute respiratory distress syndrome: lessons from computed tomography of the whole lung. Crit Care Med 31:S285–S295CrossRefPubMed

20.

Lu Q, Malbouisson LM, Mourgeon E, Goldstein I, Coriat P, Rouby JJ (2001) Assessment of PEEP-induced reopening of collapsed lung regions in acute lung injury: are one or three CT sections representative of the entire lung? Intensive Care Med 27:1504–1510CrossRefPubMed

21.

Pelosi P, Goldner M, McKibben A, Adams A, Eccher G, Caironi P, Losappio S, Gattinoni L, Marini JJ (2001) Recruitment and derecruitment during acute respiratory failure: an experimental study. Am J Respir Crit Care Med 164:122–130PubMed

22.

Crotti S, Mascheroni D, Caironi P, Pelosi P, Ronzoni G, Mondino M, Marini JJ, Gattinoni L (2001) Recruitment and derecruitment during acute respiratory failure: a clinical study. Am J Respir Crit Care Med 164:131–140PubMed

23.

Rimensberger PC, Cox PN, Frndova H, Bryan AC (1999) The open lung during small tidal volume ventilation: concepts of recruitment and “optimal” positive end-expiratory pressure. Crit Care Med 27:1946–1952CrossRefPubMed

24.

Jonson B, Richard JC, Straus C, Mancebo J, Lemaire F, Brochard L (1999) Pressure-volume curves and compliance in acute lung injury: evidence of recruitment above the lower inflection point. Am J Respir Crit Care Med 159:1172–1178PubMed

25.

Maggiore SM, Jonson B, Richard JC, Jaber S, Lemaire F, Brochard L (2001) 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 164:795–801PubMed

26.

Halter JM, Steinberg JM, Schiller HJ, DaSilva M, Gatto LA, Landas S, Nieman GF (2003) Positive end-expiratory pressure after a recruitment maneuver prevents both alveolar collapse and recruitment/derecruitment. Am J Respir Crit Care Med 167:1620–1626CrossRefPubMed

27.

Steinberg JM, Schiller HJ, Halter JM, Gatto LA, Lee HM, Pavone LA, Nieman GF (2004) Alveolar instability causes early ventilator-induced lung injury independent of neutrophils. Am J Respir Crit Care Med 169:57–63CrossRefPubMed

28.

Malbouisson LM, Muller JC, Constantin JM, Lu Q, Puybasset L, Rouby JJ (2001) Computed tomography assessment of positive end-expiratory pressure-induced alveolar recruitment in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 163:1444–1450PubMed

29.

Bugedo G, Bruhn A, Hernandez G, Rojas G, Varela C, Tapia JC, Castillo L (2003) Lung computed tomography during a lung recruitment maneuver in patients with acute lung injury. Intensive Care Med 29:218–225PubMed

30.

Puybasset L, Gusman P, Muller JC, Cluzel P, Coriat P, Rouby JJ (2000) Regional distribution of gas and tissue in acute respiratory distress syndrome. III. Consequences for the effects of positive end-expiratory pressure. CT Scan ARDS Study Group. Adult Respiratory Distress Syndrome. Intensive Care Med 26:1215–1227CrossRefPubMed

31.

Dambrosio M, Roupie E, Mollet JJ, Anglade MC, Vasile N, Lemaire F, Brochard L (1997) Effects of positive end-expiratory pressure and different tidal volumes on alveolar recruitment and hyperinflation. Anesthesiology 87:495–503CrossRefPubMed

32.

Nieszkowska A, Lu Q, Vieira S, Elman M, Fetita C, Rouby JJ (2004) Incidence and regional distribution of lung overinflation during mechanical ventilation with positive end-expiratory pressure. Crit Care Med 32:1496–1503CrossRefPubMed

33.

Markhorst DG, van Genderingen HR, van Vught AJ (2004) Static pressure-volume curve characteristics are moderate estimators of optimal airway pressures in a mathematical model of (primary/pulmonary) acute respiratory distress syndrome. Intensive Care Med 30:2086–2093CrossRefPubMed

34.

Gattinoni L, Caironi P, Pelosi P, Goodman LR (2001) What has computed tomography taught us about the acute respiratory distress syndrome? Am J Respir Crit Care Med 164:1701–1711PubMed

35.

Roupie E, Dambrosio M, Servillo G, Mentec H, el Atrous S, Beydon L, Brun-Buisson C, Lemaire F, Brochard L (1995) Titration of tidal volume and induced hypercapnia in acute respiratory distress syndrome. Am J Respir Crit Care Med 152:121–128PubMed

36.

Schmitt JM, Vieillard-Baron A, Augarde R, Prin S, Page B, Jardin F (2001) Positive end-expiratory pressure titration in acute respiratory distress syndrome patients: impact on right ventricular outflow impedance evaluated by pulmonary artery Doppler flow velocity measurements. Crit Care Med 29:1154–1158CrossRefPubMed

37.

Bruhn A, Hernandez G, Bugedo G, Castillo L (2004) Effects of positive end-expiratory pressure on gastric mucosal perfusion in acute respiratory distress syndrome. Crit Care 8:R306–R311CrossRefPubMed

38.

Jonson B (2005) Elastic pressure-volume curves in acute lung injury and acute respiratory distress syndrome. Intensive Care Med 31:205–212CrossRefPubMed

39.

Hickling KG (1998) The pressure-volume curve is greatly modified by recruitment. A mathematical model of ARDS lungs. Am J Respir Crit Care Med 158:194–202PubMed

40.

Richard JC, Maggiore SM, Jonson B, Mancebo J, Lemaire F, Brochard L (2001) Influence of tidal volume on alveolar recruitment. Respective role of PEEP and a recruitment maneuver. Am J Respir Crit Care Med 163:1609–1613PubMed

41.

Brower RG, Lanken PN, MacIntyre N, Matthay MA, Morris A, Ancukiewicz M, Schoenfeld D, Thompson BT (2004) Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 351:327–336CrossRefPubMed

42.

Holzapfel L, Robert D, Perrin F, Blanc PL, Palmier B, Guerin C (1983) Static pressure-volume curves and effect of positive end-expiratory pressure on gas exchange in adult respiratory distress syndrome. Crit Care Med 11:591–597PubMed

43.

Takeuchi M, Goddon S, Dolhnikoff M, Shimaoka M, Hess D, Amato MB, Kacmarek RM (2002) Set positive end-expiratory pressure during protective ventilation affects lung injury. Anesthesiology 97:682–692CrossRefPubMed

Title: Inspiratory vs. expiratory pressure-volume curves to set end-expiratory pressure in acute lung injury
Authors: Guillermo M. Albaiceta
Luis H. Luyando
Diego Parra
Rafael Menendez
Juan Calvo
Paula Rodríguez Pedreira
Francisco Taboada
Publication date: 01-10-2005
Publisher: Springer-Verlag
Published in: Intensive Care Medicine / Issue 10/2005
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-005-2746-6

At a glance: The STEP trials

Springer Medicine

Inspiratory vs. expiratory pressure-volume curves to set end-expiratory pressure in acute lung injury

Abstract

Objective

Design and setting

Patients

Interventions

Measurements and results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Objective

Design and setting

Patients

Interventions

Measurements and results

Conclusions

Please log in to get access to this content

Other articles of this Issue 10/2005

Etomidate and intensive care physicians

Thyroid hormone levels improve the prediction of mortality among patients admitted to the intensive care unit.

Effects of short vs. prolonged mechanical ventilation on antioxidant systems in piglet diaphragm

SAPS 3—From evaluation of the patient to evaluation of the intensive care unit. Part 1: Objectives, methods and cohort description

Long-term survival from intensive care: a review

Thrombotic microangiopathies and intensive care unit: real advances?