Research

Positive end-expiratory pressure at minimal respiratory elastance represents the best compromise between mechanical stress and lung aeration in oleic acid induced lung injury

Alysson Roncally S Carvalho¹ , Frederico C Jandre¹ , Alexandre V Pino¹ , Fernando A Bozza² , Jorge Salluh³ , Rosana Rodrigues⁴ , Fabio O Ascoli² and Antonio Giannella-Neto

¹Biomedical Engineering Program, COPPE, Federal University of Rio de Janeiro, Av. Horácio Macedo, CT Bloco H-327, 2030, 21941-914, Rio de Janeiro, Brazil

²Fundação Oswaldo Cruz, Instituto de Pesquisa Clinica Evandro Chagas e Laboratório de Imunofarmacologia, IOC, Av Brasil, 4365, Manguinhos, 21045-900 Rio de Janeiro, Brazil

³National Institute of Cancer-1, ICU, Praça Cruz Vermelha, 20230-130 Rio de Janeiro, Brazil

⁴Radiodiagnostic Service, Clementino Fraga Filho Hospital, Federal University of Rio de Janeiro, R Professor Rodolpho Paulo Rocco, 255, 21-941-913 Rio de Janeiro, Brazil

author email corresponding author email

Critical Care 2007, 11:R86doi:10.1186/cc6093

Published:	9 August 2007

See related commentary by Rouby et al., http://ccforum.com/content/11/6/180 and see related letter by Markhorst et al., http://ccforum.com/content/12/1/408

Abstract

Introduction

Protective ventilatory strategies have been applied to prevent ventilator-induced lung injury in patients with acute lung injury (ALI). However, adjustment of positive end-expiratory pressure (PEEP) to avoid alveolar de-recruitment and hyperinflation remains difficult. An alternative is to set the PEEP based on minimizing respiratory system elastance (Ers) by titrating PEEP. In the present study we evaluate the distribution of lung aeration (assessed using computed tomography scanning) and the behaviour of Ers in a porcine model of ALI, during a descending PEEP titration manoeuvre with a protective low tidal volume.

Methods

PEEP titration (from 26 to 0 cmH₂O, with a tidal volume of 6 to 7 ml/kg) was performed, following a recruitment manoeuvre. At each PEEP, helical computed tomography scans of juxta-diaphragmatic parts of the lower lobes were obtained during end-expiratory and end-inspiratory pauses in six piglets with ALI induced by oleic acid. The distribution of the lung compartments (hyperinflated, normally aerated, poorly aerated and non-aerated areas) was determined and the Ers was estimated on a breath-by-breath basis from the equation of motion of the respiratory system using the least-squares method.

Results

Progressive reduction in PEEP from 26 cmH₂O to the PEEP at which the minimum Ers was observed improved poorly aerated areas, with a proportional reduction in hyperinflated areas. Also, the distribution of normally aerated areas remained steady over this interval, with no changes in non-aerated areas. The PEEP at which minimal Ers occurred corresponded to the greatest amount of normally aerated areas, with lesser hyperinflated, and poorly and non-aerated areas. Levels of PEEP below that at which minimal Ers was observed increased poorly and non-aerated areas, with concomitant reductions in normally inflated and hyperinflated areas.

Conclusion

The PEEP at which minimal Ers occurred, obtained by descending PEEP titration with a protective low tidal volume, corresponded to the greatest amount of normally aerated areas, with lesser collapsed and hyperinflated areas. The institution of high levels of PEEP reduced poorly aerated areas but enlarged hyperinflated ones. Reduction in PEEP consistently enhanced poorly or non-aerated areas as well as tidal re-aeration. Hence, monitoring respiratory mechanics during a PEEP titration procedure may be a useful adjunct to optimize lung aeration.