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Intensive Care Medicine

, Volume 43, Issue 5, pp 603–611 | Cite as

Opening pressures and atelectrauma in acute respiratory distress syndrome

  • Massimo Cressoni
  • Davide Chiumello
  • Ilaria Algieri
  • Matteo Brioni
  • Chiara Chiurazzi
  • Andrea Colombo
  • Angelo Colombo
  • Francesco Crimella
  • Mariateresa Guanziroli
  • Ivan Tomic
  • Tommaso Tonetti
  • Giordano Luca Vergani
  • Eleonora Carlesso
  • Vladimir Gasparovic
  • Luciano GattinoniEmail author
Seven-Day Profile Publication

Abstract

Purpose

Open lung strategy during ARDS aims to decrease the ventilator-induced lung injury by minimizing the atelectrauma and stress/strain maldistribution. We aim to assess how much of the lung is opened and kept open within the limits of mechanical ventilation considered safe (i.e., plateau pressure 30 cmH2O, PEEP 15 cmH2O).

Methods

Prospective study from two university hospitals. Thirty-three ARDS patients (5 mild, 10 moderate, 9 severe without extracorporeal support, ECMO, and 9 severe with it) underwent two low-dose end-expiratory CT scans at PEEP 5 and 15 cmH2O and four end-inspiratory CT scans (from 19 to 40 cmH2O). Recruitment was defined as the fraction of lung tissue which regained inflation. The atelectrauma was estimated as the difference between the intratidal tissue collapse at 5 and 15 cmH2O PEEP. Lung ventilation inhomogeneities were estimated as the ratio of inflation between neighboring lung units.

Results

The lung tissue which is opened between 30 and 45 cmH2O (i.e., always closed at plateau 30 cmH2O) was 10 ± 29, 54 ± 86, 162 ± 92, and 185 ± 134 g in mild, moderate, and severe ARDS without and with ECMO, respectively (p < 0.05 mild versus severe without or with ECMO). The intratidal collapses were similar at PEEP 5 and 15 cmH2O (63 ± 26 vs 39 ± 32 g in mild ARDS, p = 0.23; 92 ± 53 vs 78 ± 142 g in moderate ARDS, p = 0.76; 110 ± 91 vs 89 ± 93, p = 0.57 in severe ARDS without ECMO; 135 ± 100 vs 104 ± 80, p = 0.32 in severe ARDS with ECMO). Increasing the applied airway pressure up to 45 cmH2O decreased the lung inhomogeneity slightly (but significantly) in mild and moderate ARDS, but not in severe ARDS.

Conclusions

Data show that the prerequisites of the open lung strategy are not satisfied using PEEP up to 15 cmH2O and plateau pressure up to 30 cmH2O. For an effective open lung strategy, higher pressures are required. Therefore, risks of atelectrauma must be weighted versus risks of volutrauma.

Trial registration

Clinicaltrials.gov identifier: NCT01670747 (www.clinicaltrials.gov).

Keywords

Volutrauma Atelectrauma ARDS Lung recruitment Opening pressure 

Notes

Acknowledgements

The authors gratefully acknowledge Dr. Luigi Camporota for his precious comments on the manuscript.

Compliance with ethical standards

Conflicts of interest

Dr. Cressoni and Dr. Gattinoni hold an Italian patent for determination of lung inhomogeneities (0001409041). On behalf of all authors, the corresponding author states that there are no other conflicts of interest.

Supplementary material

134_2017_4754_MOESM1_ESM.pdf (630 kb)
Supplementary material 1 (PDF 629 kb)

References

  1. 1.
    Marini JJ (1994) Tracheal gas insufflation: a useful adjunct to ventilation? Thorax 49(8):735–737CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Amato M et al (1996) Improved survival in ARDS: beneficial effects of a lung protective strategy (abstract). Am J Respir Crit Care Med 2(4, Part 2):A531Google Scholar
  3. 3.
    Mead J, Takishima T, Leith D (1970) Stress distribution in lungs: a model of pulmonary elasticity. J Appl Physiol 28(5):596–608PubMedGoogle Scholar
  4. 4.
    Lachmann B (1992) Open up the lung and keep the lung open. Intensive Care Med 18(6):319–321CrossRefPubMedGoogle Scholar
  5. 5.
    Caironi P et al (2010) Lung opening and closing during ventilation of acute respiratory distress syndrome. Am J Respir Crit Care Med 181(6):578–586CrossRefPubMedGoogle Scholar
  6. 6.
    Tremblay L et al (1997) Injurious ventilatory strategies increase cytokines and c-fos m-RNA expression in an isolated rat lung model. J Clin Investig 99(5):944–952CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Ranieri VM et al (1999) Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial. JAMA 282(1):54–61CrossRefPubMedGoogle Scholar
  8. 8.
    Webb HH, Tierney DF (1974) Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressures. Protection by positive end-expiratory pressure. Am Rev Respir Dis 110(5):556–565PubMedGoogle Scholar
  9. 9.
    Protti A et al (2013) Lung stress and strain during mechanical ventilation: any difference between statics and dynamics? Crit Care Med 41(4):1046–1055CrossRefPubMedGoogle Scholar
  10. 10.
    The 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(18):1301–1308Google Scholar
  11. 11.
    Gattinoni L et al (2016) Ventilator-related causes of lung injury: the mechanical power. Intensive Care Med 42(10):1567–1575CrossRefPubMedGoogle Scholar
  12. 12.
    Pontoppidan H, Geffin B, Lowenstein E (1972) Acute respiratory failure in the adult. 2. N Engl J Med 287(15):743–752CrossRefPubMedGoogle Scholar
  13. 13.
    Bellani G et al (2016) Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA 315(8):788–800CrossRefPubMedGoogle Scholar
  14. 14.
    Hodgson C et al (2009) Recruitment manoeuvres for adults with acute lung injury receiving mechanical ventilation. Cochrane Database Syst Rev 2009(2):CD006667Google Scholar
  15. 15.
    Suzumura EA et al (2014) Effects of alveolar recruitment maneuvers on clinical outcomes in patients with acute respiratory distress syndrome: a systematic review and meta-analysis. Intensive Care Med 40(9):1227–1240CrossRefPubMedGoogle Scholar
  16. 16.
    Kacmarek RM, Kallet RH (2007) Respiratory controversies in the critical care setting. Should recruitment maneuvers be used in the management of ALI and ARDS? Respir Care 52(5):622–631 (discussion 631–5)PubMedGoogle Scholar
  17. 17.
    Brower RG et al (2004) Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 351(4):327–336CrossRefPubMedGoogle Scholar
  18. 18.
    Meade MO et al (2008) Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 299(6):637–645CrossRefPubMedGoogle Scholar
  19. 19.
    Mercat A et al (2008) Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 299(6):646–655CrossRefPubMedGoogle Scholar
  20. 20.
    Young D et al (2013) High-frequency oscillation for acute respiratory distress syndrome. N Engl J Med 368(9):806–813CrossRefPubMedGoogle Scholar
  21. 21.
    Ferguson ND et al (2013) High-frequency oscillation in early acute respiratory distress syndrome. N Engl J Med 368(9):795–805CrossRefPubMedGoogle Scholar
  22. 22.
    Caironi P et al (2015) Lung recruitability is better estimated according to the Berlin definition of acute respiratory distress syndrome at standard 5 cm H2O rather than higher positive end-expiratory pressure: a retrospective cohort study. Crit Care Med 43(4):781–790CrossRefPubMedGoogle Scholar
  23. 23.
    Gattinoni L et al (1987) Pressure-volume curve of total respiratory system in acute respiratory failure. Computed tomographic scan study. Am Rev Respir Dis 136(3):730–736CrossRefPubMedGoogle Scholar
  24. 24.
    Cressoni M et al (2014) Lung inhomogeneity in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 189(2):149–158PubMedGoogle Scholar
  25. 25.
    Cressoni M et al (2013) Limits of normality of quantitative thoracic CT analysis. Crit Care 17(3):R93CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Benjamini Y, Yekutieli D (2001) The control of the false discovery rate in multiple testing under dependency. Ann Stat 29(4):1165–1188CrossRefGoogle Scholar
  27. 27.
    R Development Core Team (2010) A language and environment for statistical computing. R Foundation for Statistical Computing, ViennaGoogle Scholar
  28. 28.
    Pelosi P et al (1994) Vertical gradient of regional lung inflation in adult respiratory distress syndrome. Am J Respir Crit Care Med 149(1):8–13CrossRefPubMedGoogle Scholar
  29. 29.
    Ghadiali SN, Gaver DP (2008) Biomechanics of liquid-epithelium interactions in pulmonary airways. Respir Physiol Neurobiol 163(1–3):232–243CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Cressoni M et al (2014) Compressive forces and computed tomography-derived positive end-expiratory pressure in acute respiratory distress syndrome. Anesthesiology 121(3):572–581CrossRefPubMedGoogle Scholar
  31. 31.
    Gattinoni L et al (1993) Regional effects and mechanism of positive end-expiratory pressure in early adult respiratory distress syndrome. JAMA 269(16):2122–2127CrossRefPubMedGoogle Scholar
  32. 32.
    Borges JB et al (2006) Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome. Am J Respir Crit Care Med 174(3):268–278CrossRefPubMedGoogle Scholar
  33. 33.
    Kacmarek RM et al (2016) Open lung approach for the acute respiratory distress syndrome: a pilot, randomized controlled trial. Crit Care Med 44(1):32–42CrossRefPubMedGoogle Scholar
  34. 34.
    Talmor D et al (2008) Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med 359(20):2095–2104CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Chiumello D et al (2014) Bedside selection of positive end-expiratory pressure in mild, moderate, and severe acute respiratory distress syndrome. Crit Care Med 42(2):252–264CrossRefPubMedGoogle Scholar
  36. 36.
    Chiumello D et al (2016) Lung recruitment assessed by respiratory mechanics and computed tomography in patients with acute respiratory distress syndrome. What is the relationship? Am J Respir Crit Care Med 193(11):1254–1263CrossRefPubMedGoogle Scholar
  37. 37.
    Pelosi P et al (1999) Sigh in acute respiratory distress syndrome. Am J Respir Crit Care Med 159(3):872–880CrossRefPubMedGoogle Scholar
  38. 38.
    Guldner A et al (2016) Comparative effects of volutrauma and atelectrauma on lung inflammation in experimental acute respiratory distress syndrome. Crit Care Med 44(9):e854–e865CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2017

Authors and Affiliations

  • Massimo Cressoni
    • 1
  • Davide Chiumello
    • 2
    • 3
  • Ilaria Algieri
    • 1
  • Matteo Brioni
    • 3
  • Chiara Chiurazzi
    • 1
  • Andrea Colombo
    • 1
  • Angelo Colombo
    • 4
  • Francesco Crimella
    • 1
  • Mariateresa Guanziroli
    • 1
  • Ivan Tomic
    • 5
  • Tommaso Tonetti
    • 6
  • Giordano Luca Vergani
    • 3
  • Eleonora Carlesso
    • 1
  • Vladimir Gasparovic
    • 5
  • Luciano Gattinoni
    • 6
    Email author
  1. 1.Dipartimento di Fisiopatologia Medico-Chirurgica e dei TrapiantiUniversità degli Studi di MilanoMilanItaly
  2. 2.Dipartimento di Scienze della SaluteUniversità degli Studi di MilanoMilanItaly
  3. 3.Struttura Complessa Anestesia e Rianimazione ASST Santi Paolo e CarloMilanItaly
  4. 4.Ospedale Maggiore PoliclinicoMilanItaly
  5. 5.Department of Intensive Care Medicine, Rebro HospitalUniversity of ZagrebZagrebCroatia
  6. 6.Department of Anesthesiology, Emergency and Intensive Care MedicineUniversity of GöttingenGöttingenGermany

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