Experiments were approved by the animal ethics committee of the University of Uppsala. Forty-four pigs were anesthetized and mechanically ventilated in the supine position. The animals of each group were further randomly assigned into subgroups receiving either PCV with SB (PCV + SB) or without SB (PCV – SB). Anesthesia, tracheotomy, and fluid infusion were performed as previously described 12. A detailed description of measurements and statistical analysis is provided in Additional data file 1.

Instrumentation of the animals has been described previously 19. Heart rate (HR) and intravascular pressures were measured using standard technology 19. Cardiac output (CO) and intrathoracic blood volume (ITBV) were determined with the transpulmonary thermal-indicator dilution technique 19. Systemic and pulmonary vascular resistances were calculated using standard equations. Gas flow and derived variables, as well as airway and P_es values, were continuously determined and stored on personal computers for offline analyses. Blood gases were analyzed using standard blood gas electrodes, and oxygen saturation and hemoglobin were analyzed using spectrophotometry. V˙A/Q˙ MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuqqRPxAKvMB6bYrY9gDLn3AGiuraeXatLxBI9gBaebbnrfifHhDYfgasaacPi6xNi=xH8viVGI8Gi=hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY=rqGqVepae9pg0db9vqaiVgFr0xfr=xfr=xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaWaaSGbaeaacuWGwbGvgaGaamaaBaaaleaacqWGbbqqaeqaaaGcbaGafmyuaeLbaiaaaaaaaa@3199@ distribution was measured using the multiple inert gas elimination technique (MIGET) 20. Spiral scans were performed at the end of the experiments for determination of density distributions and pulmonary air content, which should represent EELV. Scans were carried out in randomized directions at end-inspiration and end-expiration with the tube clamped, and images were stored on personal computers for offline analysis.

An illustration of the study protocol is given in Figure 1. In brief, blood gases and hemodynamic and ventilatory parameters were obtained 30 minutes after completing instrumentation (Pre-ALI) and 60 minutes after completing initiation of ALI (BL-ALI), together with the first MIGET measurement, and the animals were subjected to controlled mechanical ventilation without SB. Thereafter, animals of the two groups (HCl-induced and OA-induced ALI) were further randomly assigned either to continue with controlled mechanical ventilation (PCV – SB) or to additional SB (PCV + SB). After 240 minutes, another set of measurements, including MIGET and CT scans, was performed (Treatment). The overall study period was 8 hours. Four animals died in the course of the experiments: two pigs died directly after induction of lung injury; in two others, for technical reasons, no CT scans were obtained, resulting in n = 11 in the HCl-ALI PCV + SB group, n = 11 in the HCl-ALI PCV – SB group, n = 8 in the OA-ALI PCV + SB group, and n = 10 in the OA-ALI PCV – SB group.

To detect differences in PaO₂/FiO₂, shunt fraction, EELV, and amount of non-aerated lung between the ventilatory setting and lung injury groups with the given parallel design at a significance level of 5% (α = 0.05) with a probability of 80% (β = 0.20) based on an estimated difference of 0.62 of the mean standard deviation (SD) of the parameter, the number of animals to be studied is at least 40. Results are expressed as mean ± SD, and all analyses were performed using a statistical software package (Statistica for Windows 6.0; StatSoft, Inc., Tulsa, OK, USA). Data were tested for normal distribution by the Shapiro-Wilks W test and analyzed by a two-way analysis of variance for repeated measurements with factors 'mode' and 'time'. When a significant F ratio was obtained, differences between the means were isolated for the specific factor (and for all factors in case of significant interaction) with the post hoc Tukey multiple comparison test. Differences were considered to be statistically significant for P values of less than 0.05.

Induction of ALI led to a comparable and severe hypoxemia with PaO₂/FiO₂ below 200 mm Hg in 38 out of 40 animals in both HCl-ALI and OA-ALI (Table S1 in Additional data file 1). As expected by the study design, in the HCl group, respiratory system compliance was decreased mainly by decreased lung compliance, and, in OA-ALI, due to decreased chest wall compliance associated with increased abdominal pressure (Table 1). Thus, in HCl-ALI, mean transpulmonary airway pressure (P_{transp, mean}) was higher at all times after induction of ALI (P < 0.05), and the dynamic intrinsic PEEP (PEEP_{I, dyn}) was not influenced by the type of injury (Table 1). In both models, RR and airway pressures (Table 1) had to be increased to maintain alveolar ventilation (minute ventilation [V_E]) after ALI induction. In the OA group, EELV and longitudinal lung dimensions (distances of apex – dome and apex – costodiaphragmatic recessus) were significantly smaller than in the HCl group (P < 0.05, Table S4 in Additional data file 1). In HCl-ALI, shunt decreased after 4 hours of treatment (P < 0.05, Table 2), whereas dead space ventilation (V˙A/Q˙ MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuqqRPxAKvMB6bYrY9gDLn3AGiuraeXatLxBI9gBaebbnrfifHhDYfgasaacPi6xNi=xH8viVGI8Gi=hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY=rqGqVepae9pg0db9vqaiVgFr0xfr=xfr=xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaWaaSGbaeaacuWGwbGvgaGaamaaBaaaleaacqWGbbqqaeqaaaGcbaGafmyuaeLbaiaaaaaaaa@3199@ → ∞) increased irrespective of ALI type and ventilatory mode (P < 0.05, effect time).

For both types of ALI, the CT scans showed a gravity-dependent distribution of non-aerated tissue, predominantly in the dorsal areas (P < 0.05), and the aerated tissue found in the ventral parts of the lung (P < 0.05) (Figure 2). This effect is more pronounced in the juxtadiaphragmatic lung regions (P < 0.05) compared with the apical parts of the lung and is not dependent on the ALI type. The shunt fraction determined with the MIGET correlates with the amount of non-aerated lung tissue observed in the spiral CT scans (HCl-ALI: y = 0.85 x - 0.02, R² = 0.58; OA-ALI: y = 1.19 x - 0.03, R² = 0.84). In HCl-generated ALI, however, the amount of non-aerated tissue is increased in the right region of interest (ROI) (P < 0.05), whereas an increase in aeration is found in the left ROI (P < 0.05). The SD of non-aerated tissue (SD_atelect) and the fraction of non-aerated tissue per ROI (SD%_atelect) over all slices of the spiral scans did not differ between the two models of ALI (SD_atelect: 4.3 versus 3.9; SD%_atelect: 0.13 versus 0.13, for HCl-induced versus OA-induced ALI).

In PCV – SB, PaO₂/FiO₂ deteriorated significantly (P < 0.05 for interaction of time and ventilatory mode) (Table 2). CT scans showed a greater fraction of non-aerated tissue in this group (P < 0.05, Figure 2). V_T decreased slightly as compared with baseline ALI (P < 0.05), whereas PaCO₂ increased (P < 0.05) despite higher mean airway (P_{aw, mean}) and transpulmonary (P_{transp, mean}) pressures (P < 0.05) (Table 1). CO increased during the 4-hour treatment period in this group (P < 0.05) (Table 2), and a marked increase in blood flow to shunt regions (V˙A/Q˙ MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuqqRPxAKvMB6bYrY9gDLn3AGiuraeXatLxBI9gBaebbnrfifHhDYfgasaacPi6xNi=xH8viVGI8Gi=hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY=rqGqVepae9pg0db9vqaiVgFr0xfr=xfr=xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaWaaSGbaeaacuWGwbGvgaGaamaaBaaaleaacqWGbbqqaeqaaaGcbaGafmyuaeLbaiaaaaaaaa@3199@ = 0) (P < 0.05, Table 2) with a reduction in blood flow to regions with a normal V˙A/Q˙ MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuqqRPxAKvMB6bYrY9gDLn3AGiuraeXatLxBI9gBaebbnrfifHhDYfgasaacPi6xNi=xH8viVGI8Gi=hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY=rqGqVepae9pg0db9vqaiVgFr0xfr=xfr=xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaWaaSGbaeaacuWGwbGvgaGaamaaBaaaleaacqWGbbqqaeqaaaGcbaGafmyuaeLbaiaaaaaaaa@3199@ (0.1 <V˙A/Q˙ MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuqqRPxAKvMB6bYrY9gDLn3AGiuraeXatLxBI9gBaebbnrfifHhDYfgasaacPi6xNi=xH8viVGI8Gi=hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY=rqGqVepae9pg0db9vqaiVgFr0xfr=xfr=xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaWaaSGbaeaacuWGwbGvgaGaamaaBaaaleaacqWGbbqqaeqaaaGcbaGafmyuaeLbaiaaaaaaaa@3199@ < 10) was observed (Figure 3).

PCV + SB improved PaO₂/FiO₂ during 4 hours of treatment (P < 0.05, interaction time course and ventilatory mode, Table 2). Overall lung density was lower compared with PCV – SB (P < 0.05); accordingly, the fraction of normally aerated tissue was higher in the PCV + SB group (P < 0.05) (Figure 4). The EELV and longitudinal lung dimensions were greater during SB compared with the PCV – SB group (P < 0.05). These effects were independent of the ALI type, with EELV and longitudinal dimensions always greater in HCl-ALI. SB led to an increase in RR (P < 0.05) with a concomitant decrease in VT (P < 0.05) and increases in V_E and PaCO₂. The increase in PaCO₂, however, was lower as compared with PCV – SB (P < 0.05, Table 1). The V_T of spontaneous breaths was lower in the OA-ALI group. The increases in P_{aw, mean} and P_{transp, mean} (P < 0.05) were comparable with the increases in the PCV – SB group, PEEP was comparable in the two groups, and PEEP_{I, dyn} was not significantly different between the two groups and was less than 1 cm H₂O. Blood flow to low V˙A/Q˙ MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuqqRPxAKvMB6bYrY9gDLn3AGiuraeXatLxBI9gBaebbnrfifHhDYfgasaacPi6xNi=xH8viVGI8Gi=hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY=rqGqVepae9pg0db9vqaiVgFr0xfr=xfr=xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaWaaSGbaeaacuWGwbGvgaGaamaaBaaaleaacqWGbbqqaeqaaaGcbaGafmyuaeLbaiaaaaaaaa@3199@ compartments (0.005 <V˙A/Q˙ MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuqqRPxAKvMB6bYrY9gDLn3AGiuraeXatLxBI9gBaebbnrfifHhDYfgasaacPi6xNi=xH8viVGI8Gi=hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY=rqGqVepae9pg0db9vqaiVgFr0xfr=xfr=xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaWaaSGbaeaacuWGwbGvgaGaamaaBaaaleaacqWGbbqqaeqaaaGcbaGafmyuaeLbaiaaaaaaaa@3199@ < 0.1) increased during PCV + SB in the HCl group only (P < 0.001, Table S5 in Additional data file 1). In both groups, PCV – SB and PCV + SB, the HR and mean arterial pressure (MAP) increased during the 4-hour treatment period (P < 0.05), whereas central venous pressure (CVP) and systemic vascular resistance (SVR) dropped (P < 0.05, Table 2), and pulmonary artery occlusion pressure (PAOP) and ITBV remained unchanged (Table S3 in Additional data file 1).

Although one should be careful in drawing conclusions from findings in animal models for treatment of patients with ARDS, our different lung injury types mimic relevant aspects of the clinical situation. HCl aspiration damaged the alveolar epithelium and increased lung elastance usually due to alveolar flooding and collapse, reduced removal of edema fluid, and reduced production of surfactant 4212223. Commonly, HCl-induced ALI is regarded as a form of direct ALI. OA injection combined with abdominal hypertension 1 causes damage to the vascular endothelium, resulting in increased chest wall elastance usually associated with microvascular congestion, interstitial edema, and recruitment of inflammatory cells, whereas the intra-alveolar spaces are spared 24, mimicking indirect ALI. Although OA exhibits direct toxicity to endothelial cells 25, the elicited lung injury might not be similar to ALI caused by sepsis. However, OA generates a reproducible injury within a reasonable time frame.

According to our knowledge, the differences of direct and indirect ALI/ARDS have been described qualitatively only, revealing a heterogeneous distribution pattern (for example, 'patchy pattern') of normal lung, regions with ground-glass opacity, and consolidated areas. In the current literature, different distribution patterns of inhomogeneities are described 252627. We attempted to quantify the heterogeneities by determining the SD of density distributions in eight ROIs per transverse slide assessed with spiral CT scans. However, this approach did not reveal any quantitative differences and the authors were not able to distinguish the type of injury by visual inspection in a significant number of animals. This suggests either that there are no morphological differences between these models of ALI or that the differences are too small to be detected with the used CT technique. Desai and colleagues 8 were not able to describe a single CT feature to predict whether ARDS in humans is of direct or indirect origin. These findings suggest that both injury types result in interstitial pulmonary edema as a common final path. The greater amount of injury in the right lungs in HCl-induced ALI is well known from aspiration pneumonia.

The additional fluid volume infused into the abdominal cavity in the OA group influences hemodynamic parameters; MAP was higher in the OA group (P < 0.05, effect injury type) as an effect of an increased SVR (P < 0.05, effect injury type; Table 2), and CO was not different between the injury models. However, the ITBV was not significantly different between OA-induced and HCl-induced ALI (Table W3 in Additional data file 1), and on average very little normal saline had to be replaced for maintaining IAP ( < 100 mL), thus effects other than intravascular shifting of intraperitoneal fluid might account for this.

The rationale to investigate the effects of SB in two different ALI models was that they might differ in their potential for recruitment 12829. Recruitment maneuvers differ in their effect on oxygenation and lung mechanics in an animal model of intratracheal and intraperitoneal lipopolysaccharide injections, with recruitment maneuvers being more effective in animals with intraperitoneally injected lipopolysaccharide 29. Recent data, however, challenged this concept: a multicenter CT study in 68 patients with ALI or ARDS was unable to detect any difference in alveolar recruitment potential depending on the type of ALI, but huge individual differences were detected 30. A recent study found the volume recruited by different levels of PEEP (10 and 14 cm H₂O) in patients with direct and indirect ARDS to be similar, but classification of ARDS was uncertain in more than one third (37%) of patients 31. The PEEP used in this study was considerably low and might not have prevented atelectasis formation. The aim of this study, however, was to study the effects of SB in different ALI models and not the effects of other recruitment strategies such as recruitment maneuvers or high PEEP. Intrinsic PEEP was below 1 cm H₂O in all situations and therefore was not considered clinically significant. The meta-analysis of studies did not find any differences in outcome in patients with direct or indirect ALI/ARDS 32. These recent findings suggest that differences in alveolar recruitment potential are attributable to individual differences between patients rather than to the systematic origin of ALI/ARDS. This is in line with our experimental findings that beneficial effects of SB on lung recruitment do not depend on the origin of ALI/ARDS.

PCV + SB resulted in a higher EELV, greater lung dimensions, and less non-aerated tissue (Figure 4), indicating that SB prevents a loss of aeration. During SB, the posterior muscular sections of the diaphragm move more than the anterior tendon plate 17 and ventilation is shifted to the dependent lung regions 33, thereby counteracting atelectasis formation and resulting in improvement in V˙A/Q˙ MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuqqRPxAKvMB6bYrY9gDLn3AGiuraeXatLxBI9gBaebbnrfifHhDYfgasaacPi6xNi=xH8viVGI8Gi=hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY=rqGqVepae9pg0db9vqaiVgFr0xfr=xfr=xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaWaaSGbaeaacuWGwbGvgaGaamaaBaaaleaacqWGbbqqaeqaaaGcbaGafmyuaeLbaiaaaaaaaa@3199@ matching 1416. The finding that EELV was lower in OA-induced ALI can be explained by the elevated IAP and, as a consequence, a cranial displacement of the diaphragm with compression atelectasis or consolidation of the juxtadiaphramatic lung regions 3435.

V_T tended to be smaller when SB was maintained. This is a consequence of the unsupported spontaneous breaths, which occurred on the lower pressure level only. The spontaneous V_T (V_Tsb) was lower in the OA group due to the more cranially displaced diaphragm compared with the HCl group. As spontaneous breaths coincided with mechanical breaths delivered by the ventilator, it is difficult to determine the V_T solely generated by ventilator. With the high spontaneous RR on the lower pressure level, plausible 'ventilator V_T' could not be calculated.

The good correlation of the shunt fraction determined with the MIGET with the amount of non-aerated lung tissue observed in the spiral CT scans has already been shown by others 5. This suggests that loss of aeration (also indicated by the reduction in EELV) was the main reason for the shunt fraction and that the prevention of this loss of aeration in these lung areas by SB contributed to the improvement in oxygenation, regardless of ALI type. This is in agreement with previous studies reporting a reduction in intrapulmonary shunting in PCV with SB 1012163637. Intrapulmonary shunt in ARDS/ALI has been found to correlate directly with the quantity of non-aerated tissue in dependent lung regions 51438. In HCl-induced ALI with maintained SB, the blood flow to low V˙A/Q˙ MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuqqRPxAKvMB6bYrY9gDLn3AGiuraeXatLxBI9gBaebbnrfifHhDYfgasaacPi6xNi=xH8viVGI8Gi=hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY=rqGqVepae9pg0db9vqaiVgFr0xfr=xfr=xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaWaaSGbaeaacuWGwbGvgaGaamaaBaaaleaacqWGbbqqaeqaaaGcbaGafmyuaeLbaiaaaaaaaa@3199@ (0.005 <V˙A/Q˙ MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuqqRPxAKvMB6bYrY9gDLn3AGiuraeXatLxBI9gBaebbnrfifHhDYfgasaacPi6xNi=xH8viVGI8Gi=hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY=rqGqVepae9pg0db9vqaiVgFr0xfr=xfr=xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaWaaSGbaeaacuWGwbGvgaGaamaaBaaaleaacqWGbbqqaeqaaaGcbaGafmyuaeLbaiaaaaaaaa@3199@ < 0.1) was significantly higher than in HCl-ALI without SB and in OA-ALI with and without SB. HCl instillation led to alveolar flooding and collapse, and the physiologic response is to divert blood flow away from non-ventilated regions (hypoxic pulmonary vasoconstriction). PCV + SB in HCl-induced ALI might have restored ventilation in those regions and might have led to an increase in perfused low V˙A/Q˙ MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuqqRPxAKvMB6bYrY9gDLn3AGiuraeXatLxBI9gBaebbnrfifHhDYfgasaacPi6xNi=xH8viVGI8Gi=hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY=rqGqVepae9pg0db9vqaiVgFr0xfr=xfr=xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaWaaSGbaeaacuWGwbGvgaGaamaaBaaaleaacqWGbbqqaeqaaaGcbaGafmyuaeLbaiaaaaaaaa@3199@ areas that participate in gas exchange. The effects of low V˙A/Q˙ MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuqqRPxAKvMB6bYrY9gDLn3AGiuraeXatLxBI9gBaebbnrfifHhDYfgasaacPi6xNi=xH8viVGI8Gi=hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY=rqGqVepae9pg0db9vqaiVgFr0xfr=xfr=xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaWaaSGbaeaacuWGwbGvgaGaamaaBaaaleaacqWGbbqqaeqaaaGcbaGafmyuaeLbaiaaaaaaaa@3199@ on blood oxygenation, however, will depend on FiO₂. With low FiO₂, low V˙A/Q˙ MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuqqRPxAKvMB6bYrY9gDLn3AGiuraeXatLxBI9gBaebbnrfifHhDYfgasaacPi6xNi=xH8viVGI8Gi=hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY=rqGqVepae9pg0db9vqaiVgFr0xfr=xfr=xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaWaaSGbaeaacuWGwbGvgaGaamaaBaaaleaacqWGbbqqaeqaaaGcbaGafmyuaeLbaiaaaaaaaa@3199@ regions contribute to impaired oxygenation, but at high FiO₂ there will be no substantial effect. High FiO₂ will more easily cause collapse (atelectasis) of the low V˙A/Q˙ MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuqqRPxAKvMB6bYrY9gDLn3AGiuraeXatLxBI9gBaebbnrfifHhDYfgasaacPi6xNi=xH8viVGI8Gi=hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY=rqGqVepae9pg0db9vqaiVgFr0xfr=xfr=xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaWaaSGbaeaacuWGwbGvgaGaamaaBaaaleaacqWGbbqqaeqaaaGcbaGafmyuaeLbaiaaaaaaaa@3199@ regions. The deterioration in oxygenation in the PCV – SB group can be explained by the reduced blood flow to normal V˙A/Q˙ MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuqqRPxAKvMB6bYrY9gDLn3AGiuraeXatLxBI9gBaebbnrfifHhDYfgasaacPi6xNi=xH8viVGI8Gi=hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY=rqGqVepae9pg0db9vqaiVgFr0xfr=xfr=xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaWaaSGbaeaacuWGwbGvgaGaamaaBaaaleaacqWGbbqqaeqaaaGcbaGafmyuaeLbaiaaaaaaaa@3199@ (0.1 <V˙A/Q˙ MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuqqRPxAKvMB6bYrY9gDLn3AGiuraeXatLxBI9gBaebbnrfifHhDYfgasaacPi6xNi=xH8viVGI8Gi=hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY=rqGqVepae9pg0db9vqaiVgFr0xfr=xfr=xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaWaaSGbaeaacuWGwbGvgaGaamaaBaaaleaacqWGbbqqaeqaaaGcbaGafmyuaeLbaiaaaaaaaa@3199@ < 10) and the concomitant increase in shunt after 4 hours of treatment. The greater dispersion of blood flow (logSD_Q) in HCl-induced lung injury after 4 hours of treatment might indicate damage that is more severe 39. However, this does not translate into a greater deterioration of oxygenation. SB, on the other hand, had no effect on the dispersion of ventilation distribution. Thus, impairments in oxygenation in the PCV – SB group are caused by the increase in shunt. All animals showed a unimodal distribution of perfusion and ventilation, and the residual sum of squares (RSS) was exceptionally low, indicating adequate MIGET data 39.

In contrast to previously published data 10111213163637, we observed an increase in CO during PCV – SB over the 4-hour treatment period. An animal study found less depression of CO and oxygen delivery (DO₂) with PCV + SB compared with PCV at similar transpulmonary pressures 40. In our study, the CO during PCV + SB and PCV – SB was comparable to previously published studies 1216., and the more pronounced increase in the PCV – SB group does not lead to a significant increase in DO₂. This suggests that the higher CO was required to maintain an adequate DO₂. Linear regression analysis revealed a reasonable inverse correlation between PaO₂/FiO₂ and CO during PCV + SB (r² = 0.42, P < 0.05) after the 4-hour treatment period compared with r² = 0.23 (P < 0.05) in the PCV – SB group. The change in CO is positively correlated with the increase in intrapulmonary shunt (r² = 0.36), which is in line with previously conducted studies 41. However, as the time frame of our experiments was relatively short, one has to be careful to extrapolate the results on patients with impaired CO due to, for example, septic cardiomyopathy. The increase in CO after 4 hours of treatment in the controlled mechanical ventilation group might also be explained by the increased PaCO₂ and the lower pH; also, the latter was not statistically significant. In the OA group subjected to controlled mechanical ventilation, the drop in SVR is especially pronounced, which might explain the highest CO in this group. The ITBV indicates comparable volume status. However, the CVP and the MAP were higher in the indirect ALI group, most likely due to elevated IAP 74243. The mode of ventilation did not influence oxygen consumption (VO₂), which is in line with previous observations 1014, whereas VO₂ was significantly lower in the OA-induced ALI group, most likely as a consequence of impaired organ perfusion due to increased abdominal pressure.

In this study, we used time-cycled PCV with suppression of SB compared with PCV with maintained SB (also termed airway pressure release ventilation [APRV] or biphasic positive airway pressure [bi-level]). Currently, a number of ventilatory modes supporting SB are available and have been used in animal models of ALI. Noisy pressure support ventilation improved oxygenation and reduced venous admixture at a lower P_{aw, mean} compared with PCV in a model of surfactant depletion 44. On comparing PCV with different modes of assisted SB (biphasic positive airway pressure, pressure-controlled assisted ventilation, and pressure support ventilation) in a saline lavage animal model, assisted SB was found to be superior to PCV in terms of oxygenation and hemodynamic parameters 45. The transpulmonary pressure was different in our groups as a result of the increased IAP in the OA group and the comparable PEEP in both groups. Increasing the PEEP to match the groups for transpulmonary pressure could have influenced the results, but this was beyond our scope to investigate the effects of SB. Although several studies reported beneficial effects of SB in ALI, we were able to show that PCV with maintained SB has positive effects regardless of the model of ALI used in our study.