Alveolar Tidal recruitment/derecruitment and Overdistension During Four Levels of End-Expiratory Pressure with Protective Tidal Volume During Anesthesia in a Murine Lung-Healthy Model
We compared respiratory mechanics between the positive end-expiratory pressure of minimal respiratory system elastance (PEEPminErs) and three levels of PEEP during low-tidal-volume (6 mL/kg) ventilation in rats.
Twenty-four rats were anesthetized, paralyzed, and mechanically ventilated. Airway pressure (Paw), flow (F), and volume (V) were fitted by a linear single compartment model (LSCM) Paw(t) = Ers × V(t) + Rrs × F(t) + PEEP or a volume- and flow-dependent SCM (VFDSCM) Paw(t) = (E1 + E2 × V(t)) × V(t) + (K1 + K2 × |F(t)|) × F(t) + PEEP, where Ers and Rrs are respiratory system elastance and resistance, respectively; E1 and E2× V are volume-independent and volume-dependent Ers, respectively; and K1 and K2 × F are flow-independent and flow-dependent Rrs, respectively. Animals were ventilated for 1 h at PEEP 0 cmH2O (ZEEP); PEEPminErs; 2 cmH2O above PEEPminErs (PEEPminErs+2); or 4 cmH2O above PEEPminErs (PEEPminErs+4). Alveolar tidal recruitment/derecruitment and overdistension were assessed by the index %E2 = 100 × [(E2 × VT)/(E1 + |E2| × VT)], and alveolar stability by the slope of Ers(t).
%E2 varied between 0 and 30% at PEEPminErs in most respiratory cycles. Alveolar Tidal recruitment/derecruitment (%E2 < 0) and overdistension (%E2 > 30) were predominant in the absence of PEEP and in PEEP levels higher than PEEPminErs, respectively. The slope of Ers(t) was different from zero in all groups besides PEEPminErs+4.
PEEPminErs presented the best compromise between alveolar tidal recruitment/derecruitment and overdistension, during 1 h of low-VT mechanical ventilation.
KeywordsAlveolar overdistention Tidal recruitment/derecruitment PEEP choice Protective ventilation Anesthesia
This study was supported by grants from the Brazilian Council for Scientific and Technology Development (CNPq)—140047/2008-5.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
All procedures performed in this study were in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guiding Principles in the Care and Use of Animals” approved by the Council of the American Physiological Society, USA. The present study was approved by the Institutional Animal Care and Use Committee (CEUA CCS, IBCCF-019).
- 3.Bregeon F, Roch A, Delpierre S, Ghigo E, Autillo-Touati A, Kajikawa O, Martin TR, Pugin J, Portugal H, Auffray JP, Jammes Y (2002) Conventional mechanical ventilation of healthy lungs induced pro-inflammatory cytokine gene transcription. Respir Physiol Neurobiol 132(2):191–203CrossRefPubMedGoogle Scholar
- 4.dos Santos CC, Slutsky AS (2006) The contribution of biophysical lung injury to the development of biotrauma. Annu Rev Physiol 68:585–618. https://doi.org/10.1146/annurev.physiol.68.072304.113443 CrossRefPubMedGoogle Scholar
- 6.Wolthuis EK, Choi G, Dessing MC, Bresser P, Lutter R, Dzoljic M, van der Poll T, Vroom MB, Hollmann M, Schultz MJ (2008) Mechanical ventilation with lower tidal volumes and positive end-expiratory pressure prevents pulmonary inflammation in patients without preexisting lung injury. Anesthesiology 108(1):46–54. https://doi.org/10.1097/01.anes.0000296068.80921.10 CrossRefPubMedGoogle Scholar
- 9.D’Antini D, Huhle R, Herrmann J, Sulemanji DS, Oto J, Raimondo P, Mirabella L, Hemmes SNT, Schultz MJ, Pelosi P, Kaczka DW, Vidal Melo MF, Gama de Abreu M, Cinnella G, European Society of A., The PVN (2018) Respiratory system mechanics during low versus high positive end-expiratory pressure in open abdominal surgery: a substudy of PROVHILO randomized controlled trial. Anesth Analg 126(1):143–149. https://doi.org/10.1213/ANE.0000000000002192 CrossRefPubMedGoogle Scholar
- 10.Futier E, Constantin JM, Paugam-Burtz C, Pascal J, Eurin M, Neuschwander A, Marret E, Beaussier M, Gutton C, Lefrant JY, Allaouchiche B, Verzilli D, Leone M, De Jong A, Bazin JE, Pereira B, Jaber S, Group IS (2013) A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med 369(5):428–437. https://doi.org/10.1056/NEJMoa1301082 CrossRefPubMedGoogle Scholar
- 12.Carvalho AR, Jandre FC, Pino AV, Bozza FA, Salluh JI, Rodrigues R, Soares JH, Giannella-Neto A (2006) Effects of descending positive end-expiratory pressure on lung mechanics and aeration in healthy anaesthetized piglets. Crit Care 10(4):R122. https://doi.org/10.1186/cc5030 CrossRefPubMedPubMedCentralGoogle Scholar
- 13.Carvalho AR, Spieth PM, Pelosi P, Vidal Melo MF, Koch T, Jandre FC, Giannella-Neto A, de Abreu MG (2008) Ability of dynamic airway pressure curve profile and elastance for positive end-expiratory pressure titration. Intensive Care Med 34(12):2291–2299. https://doi.org/10.1007/s00134-008-1301-7 CrossRefPubMedPubMedCentralGoogle Scholar
- 16.Carvalho AR, Jandre FC, Pino AV, Bozza FA, Salluh J, Rodrigues R, Ascoli FO, Giannella-Neto A (2007) Positive end-expiratory pressure at minimal respiratory elastance represents the best compromise between mechanical stress and lung aeration in oleic acid induced lung injury. Crit Care 11(4):R86. https://doi.org/10.1186/cc6093 CrossRefPubMedPubMedCentralGoogle Scholar
- 20.Carvalho AR, Pacheco SA, de Souza Rocha PV, Bergamini BC, Paula LF, Jandre FC, Giannella-Neto A (2013) Detection of tidal recruitment/overdistension in lung-healthy mechanically ventilated patients under general anesthesia. Anesth Analg 116(3):677–684. https://doi.org/10.1213/ANE.0b013e318254230b CrossRefPubMedGoogle Scholar
- 21.Holm S (1979) A simple sequentially rejective multiple test procedure. Scand J Stat 6(2):65–70Google Scholar
- 22.Carvalho AR, Bergamini BC, Carvalho NS, Cagido VR, Neto AC, Jandre FC, Zin WA, Giannella-Neto A (2013) Volume-independent elastance: a useful parameter for open-lung positive end-expiratory pressure adjustment. Anesth Analg 116(3):627–633. https://doi.org/10.1213/ANE.0b013e31824a95ca CrossRefPubMedGoogle Scholar
- 28.Jaber S, Coisel Y, Chanques G, Futier E, Constantin JM, Michelet P, Beaussier M, Lefrant JY, Allaouchiche B, Capdevila X, Marret E (2012) A multicentre observational study of intra-operative ventilatory management during general anaesthesia: tidal volumes and relation to body weight. Anaesthesia 67(9):999–1008. https://doi.org/10.1111/j.1365-2044.2012.07218.x CrossRefPubMedGoogle Scholar
- 30.Pintado MC, de Pablo R, Trascasa M, Milicua JM, Rogero S, Daguerre M, Cambronero JA, Arribas I, Sanchez-Garcia M (2013) Individualized PEEP setting in subjects with ARDS: a randomized controlled pilot study. Respir Care 58(9):1416–1423. https://doi.org/10.4187/respcare.02068 CrossRefPubMedGoogle Scholar
- 33.Thammanomai A, Hamakawa H, Bartolak-Suki E, Suki B (2013) Combined effects of ventilation mode and positive end-expiratory pressure on mechanics, gas exchange and the epithelium in mice with acute lung injury. PloS ONE 8(1):e53934. https://doi.org/10.1371/journal.pone.0053934 CrossRefPubMedPubMedCentralGoogle Scholar
- 34.Camilo LM, Avila MB, Cruz LF, Ribeiro GC, Spieth PM, Reske AA, Amato M, Giannella-Neto A, Zin WA, Carvalho AR (2014) Positive end-expiratory pressure and variable ventilation in lung-healthy rats under general anesthesia. PloS ONE 9(11):e110817. https://doi.org/10.1371/journal.pone.0110817 CrossRefPubMedPubMedCentralGoogle Scholar
- 36.Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial I, Cavalcanti AB, Suzumura EA, Laranjeira LN, Paisani DM, Damiani LP, Guimaraes HP, Romano ER, Regenga MM, Taniguchi LNT, Teixeira C, Pinheiro de Oliveira R, Machado FR, Diaz-Quijano FA, Filho MSA, Maia IS, Caser EB, Filho WO, Borges MC, Martins PA, Matsui M, Ospina-Tascon GA, Giancursi TS, Giraldo-Ramirez ND, Vieira SRR, Assef M, Hasan MS, Szczeklik W, Rios F, Amato MBP, Berwanger O, Ribeiro de Carvalho CR (2017) Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) vs low PEEP on mortality in patients with acute respiratory distress syndrome: a randomized clinical trial. JAMA 318 (14):1335–1345. https://doi.org/10.1001/jama.2017.14171 CrossRefGoogle Scholar
- 37.Amato MB, Meade MO, Slutsky AS, Brochard L, Costa EL, Schoenfeld DA, Stewart TE, Briel M, Talmor D, Mercat A, Richard JC, Carvalho CR, Brower RG (2015) Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 372(8):747–755. https://doi.org/10.1056/NEJMsa1410639 CrossRefPubMedGoogle Scholar
- 38.Neto AS, Hemmes SNT, Barbas CSV, Beiderlinden M, Fernandez-Bustamante A, Futier E, Gajic O, El-Tahan MR, Ghamdi AAA, Günay E, Jaber S, Kokulu S, Kozian A, Licker M, Lin W-Q, Maslow AD, Memtsoudis SG, Miranda DR, Moine P, Ng T, Paparella D, Ranieri VM, Scavonetto F, Schilling T, Selmo G, Severgnini P, Sprung J, Sundar S, Talmor D, Treschan T, Unzueta C, Weingarten TN, Wolthuis EK, Wrigge H, Amato MBP, Costa ELV, de Abreu MG, Pelosi P, Schultz MJ (2016) Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia: a meta-analysis of individual patient data. Lancet Respir Med 4(4):272–280. https://doi.org/10.1016/s2213-2600(16)00057-6 CrossRefPubMedGoogle Scholar
- 41.Kolobow T, Moretti MP, Fumagalli R, Mascheroni D, Prato P, Chen V, Joris M (1987) Severe impairment in lung function induced by high peak airway pressure during mechanical ventilation. An experimental study. Am Rev Respir Dis 135(2):312–315. https://doi.org/10.1164/arrd.1922.214.171.1242 PubMedGoogle Scholar
- 42.Parker JC, Hernandez LA, Longenecker GL, Peevy K, Johnson W (1990) Lung edema caused by high peak inspiratory pressures in dogs. Role of increased microvascular filtration pressure and permeability. Am Rev Respir Dis 142(2):321–328. https://doi.org/10.1164/ajrccm/142.2.321 CrossRefPubMedGoogle Scholar