Positive End-Expiratory Pressure Prevents the Loss of Respiratory Compliance During Low Tidal Volume Ventilation in Acute Lung Injury Patients

doi:10.1378/chest.109.2.480

Chest

Volume 109, Issue 2, February 1996, Pages 480-485

https://doi.org/10.1378/chest.109.2.480 Get rights and content

Study objective

To study the effect of positive end-expiratory pressure (PEEP) on the decay of respiratory system compliance (Cpl, rs) due to low tidal volume (VT) ventilation in acute lung injury (ALI) patients.

Setting

General ICU in a university hospital.

Participants

Eight ALI patients with a lung injury score greater than 2.5.

Interventions

Pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV), with an average VT of 8.5 ± 0.4 mL/kg, were applied at three levels of PEEP (5, 10, and 15 cm H₂O). Before each PCV and VCV period, lung volume history was standardized by manual hyperinflation maneuvers.

Measurements

We measured Cpl, rs at time 0 (start), 10, 20, and 30 (end) min from the beginning of each PCV and VCV period. Gas exchange and hemodynamic data were collected at end.

Results

At PEEP 5 and 10 cm H₂O, we observed a progressive Cpl, rs decay with both PCV and VCV modes. At PEEP 5 cm H₂O, we detected a higher Cpl, rs decrease during PCV, due to a higher Cpl, rs at start, compared with VCV. At PEEP 15 cm H₂O, Cpl, rs did not decrease significantly. Cpl, rs values measured at end as well as oxygenation and hemodynamic data did not differ between PCV and VCV. At PEEP 15 cm H₂O, PCV provided lower PaCO₂ than VCV.

Conclusions

A PEEP of at least 15 cm H₂O was needed to prevent Cpl, rs decay. The progressive Cpl, rs loss we observed at lower PEEP probably reflects alveolar instability.

Section snippets

Patient Population

Eight patients with ALI were enrolled in this study according to the following criteria: (1) lung injury score of 2.5 or more;¹⁵ (2) no history of chronic obstructive lung disease; (3) no active air leak; (4) pulmonary artery occlusion pressure (PAOP) less than 18 mm Hg; and (5) stable hemodynamics during the previous 6 h. All patients were in supine position and undergoing VCV by a ventilator (Servo 900C; Siemens Elema; Solna, Sweden). All patients were under IV sedation by continuous

RESULTS

Cpl, rs decreased from start to end with both ventilatory modes (Tables 2 and 3) at PEEP 5 and 10 cm H₂O, but not at PEEP 15 cm H₂O. Figure 1 shows the average time course of Cpl, rs at the three PEEP levels during PCV and VCV periods. The Cpl, rs decay, when observed, was progressive in time, but an apparent steady state was reached by the 30th minute.

At PEEP 5 cm H₂O, the decrease of Cpl, rs was significantly higher during PCV than during VCV, even if end Cpl, rs values were comparable

DISCUSSION

The main results of this study are as follows: at PEEP 5 and 10 cm H₂O, Cpl, rs decayed from start to end during both VCV and PCV modes and PEEP 15 cm H₂O prevented this decay in Cpl, rs.

An interesting collateral finding was that, at PEEP 15 cm H₂O, PaCO₂ was lower in PCV than in VCV. The observed decay of Cpl, rs confirms the classic studies reporting a progressive Cpl, rs decrease during anesthesia.⁹ Low VT ventilation fosters Cpl, rs decay while hyperinflation maneuvers may restore Cpl, rs.¹⁰

CONCLUSIONS

In ALI patients ventilated with relatively low VT, we observed a Cpl, rs decay in time that was prevented by a 15 cm H₂O PEEP level. Progressive compliance loss during mechanical ventilation is the result of ventilatory strategies that allow the development of atelectasis.¹⁴ Experimental evidence suggests, however, that alveolar instability worsens lung injury.²⁹ Therefore, ventilatory patterns focused on lung volume recruitment are recommended as a safer choice.³⁰ In our patients, a relatively

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Cited by (64)

Factors associated with decreased compliance after on-site extracorporeal membrane oxygenation cannulation for acute respiratory distress syndrome: A retrospective, observational cohort study
2023, Journal of Intensive Medicine
Extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) is systematically associated with decreased respiratory system compliance (CRS). It remains unclear whether transportation to the referral ECMO center, changes in ventilatory mode or settings to achieve ultra-protective ventilation, or the natural evolution of ARDS drives this change in respiratory mechanics. Herein, we assessed the precise moment when CRS decreases after ECMO cannulation and identified factors associated with decreased CRS.
To rule out the effect of transportation and the different modes of ventilation on CRS, we conducted a retrospective, single-center, observational cohort study from January 2013 to May 2020, on 22 patients with severe ARDS requiring on-site ECMO and ventilated in pressure-controlled mode to achieve ultra-protective ventilation. CRS was assessed at different time points ranging from 12 h before ECMO cannulation to 72 h after ECMO cannulation. The primary outcome was the relative change in CRS between 3 h before and 3 h after ECMO cannulation. The secondary outcomes included variables associated with the relative changes in CRS within the first 3 h after ECMO cannulation and the relative changes in CRS at each time point.
CRS decreased within the first 3 h after ECMO cannulation (−28.3%, 95% confidence interval [CI]: −38.8 to −17.9, P<0.001), while the decrease was mild before and after these first 3 h after ECMO cannulation. To achieve ultra-protective ventilation, respiratory rate decreased in the mean by –13 breaths/min (95% CI: −15 to −11) and driving pressure by −8.3 cmH₂O (95% CI: −11.2 to −5.3), resulting in decreased tidal volume by −3.3 mL/kg of predicted body weight (95% CI: −3.9 to −2.6) as compared to before ECMO cannulation (P <0.001 for all). Plateau pressure reduction, driving pressure reduction, and tidal volume reduction were significantly associated with decreased CRS after ECMO cannulation, whereas neither respiratory rate, positive end-expiratory pressure, inspired fraction of oxygen, fluid balance, nor mean airway pressure was associated with decreased CRS.
Decreased driving pressure resulting in lower tidal volume to achieve ultra-protective ventilation after ECMO cannulation was associated with a marked decrease in CRS in ARDS patients with on-site ECMO cannulation.
The Patient with a Full Stomach
2013, Benumof and Hagberg's Airway Management
Ventilation strategies in obese patients undergoing surgery: A quantitative systematic review and meta-analysis
2012, British Journal of Anaesthesia
Citation Excerpt :
This result was not unexpected as previous studies in ALI and ARDS patients,42 43 or in non-obese patients undergoing thoracic surgery44 failed to show a significant difference between these two ventilation modes. As suggested by Cereda and colleagues,45 a theoretical risk of PCV in surgical patients is that the progressive decrease in compliance during anaesthesia and surgery may lead to a reduction in ventilation. These trials did not allow confirmation of this hypothesis.
Pathophysiological changes due to obesity may complicate mechanical ventilation during general anaesthesia. The ideal ventilation strategy is expected to optimize gas exchange and pulmonary mechanics and to reduce the risk of respiratory complications.
Systematic search (databases, bibliographies, to March 2012, all languages) was performed for randomized trials testing intraoperative ventilation strategies in obese patients (BMI ≥30 kg m⁻²), and reporting on gas exchange, pulmonary mechanics, or pulmonary complications. Meta-analyses were performed when data from at least three studies or 100 patients could be combined.
Thirteen studies (505 obese surgical patients) reported on a variety of ventilation strategies: pressure- or volume-controlled ventilation (PCV, VCV), various tidal volumes, and different PEEP or recruitment manoeuvres (RM), and combinations thereof. Definitions and reporting of endpoints were inconsistent. In five trials (182 patients), RM added to PEEP compared with PEEP alone improved intraoperative Pa_O₂/FI_O₂ ratio [weighted mean difference (WMD), 16.2 kPa; 95% confidence interval (CI), 8.0–24.4] and increased respiratory system compliance (WMD, 14 ml cm H₂O⁻¹; 95% CI, 8–20). Arterial pressure remained unchanged. In four trials (100 patients) comparing PCV with VCV, there was no difference in Pa_O₂/FI_O₂ ratio, tidal volume, or arterial pressure. Comparison of further ventilation strategies or combination of other outcomes was not feasible. Data on postoperative complications were seldom reported.
The ideal intraoperative ventilation strategy in obese patients remains obscure. There is some evidence that RM added to PEEP compared with PEEP alone improves intraoperative oxygenation and compliance without adverse effects. There is no evidence of any difference between PCV and VCV.
The Patient with a Full Stomach
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The basics on mechanical ventilation support in acute respiratory distress syndrome
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El síndrome de distrés respiratorio agudo (SDRA) corresponde al daño de la barrera endotelioepitelial pulmonar inducida por inflamación, cuyo resultado condiciona aumento de la permeabilidad vascular y disfunción del agente tensioactivo y produce grados variables de colapso y relleno alveolar. Actualmente, el tratamiento consiste en ventilación mecánica. El desafío actual apunta a determinar qué estrategias ventilatorias son capaces de minimizar la lesión producida por el ventilador (VILI, ventilator-induced lung injury) y a procurar un intercambio gaseoso razonable.
La evidencia muestra que debería ventilarse a los pacientes con volumen tidal entre 6–8 ml/kg, peso ideal con presión “meseta” <30 cmH₂O. El uso de altos niveles de presión positiva espiratoria final (PEEP, positive end expiratory pressure) no ha demostrado reducir la mortalidad; sin embargo, ha mejorado metas secundarias importantes. La racionalidad en el uso de niveles elevados de PEEP se fundamenta en su capacidad de reducir el colapso-reapertura cíclico de la vía aérea, probablemente el mayor culpable del desarrollo de VILI.
La tomografía computarizada de tórax ha contribuido en la comprensión anatomicofuncional de los patrones de distribución del SDRA. La tomografía de impedancia eléctrica, aunque aún está en desarrollo, es una técnica libre de radiación capaz de monitorizar dinámicamente la ventilación al lado del enfermo.
Acute Respiratory Distress Syndrome (ARDS) is understood as an inflammation-induced disruption of the alveolar endothelial-epithelial barrier that results in increased permeability and surfactant dysfunction followed by alveolar flooding and collapse. ARDS management relies on mechanical ventilation. The current challenge is to determine the optimal ventilatory strategies that minimize ventilator-induced lung injury (VILI) while providing a reasonable gas exchange.
The data support that a tidal volume between 6–8 ml/kg of predicted body weight providing a plateau pressure <30 cmH₂O should be used. High positive end expiratory pressure (PEEP) has not reduced mortality, nevertheless secondary endpoints are improved. The rationale used for high PEEP argues that it prevents cyclic opening and closing of airspaces, probably the major culprit of development of VILI.
Chest computed tomography has contributed to our understanding of anatomic-functional distribution patterns in ARDS. Electric impedance tomography is a technique that is radiation-free, but still under development, that allows dynamic monitoring of ventilation distribution at bedside.
Blast injuries
2009, The Lancet
Citation Excerpt :
When positive-pressure ventilation is needed, lung-protective techniques should be used. These strategies include maintaining acceptably low oxygen saturations (90%) and low tidal volumes (5–7 mL/kg), pressure-controlled ventilation, positive end-expiratory pressures (PEEP), and permissive hypercapnia.2,36,62,79–83 By contrast, strategies to minimise the sequelae from arterial air emboli include maximising spontaneous ventilation, low PEEP, and using 100% FiO2 to encourage quick absorption of emboli.73,84
Health-care providers are increasingly faced with the possibility of needing to care for people injured in explosions, but can often, however, feel undertrained for the unique aspects of the patient's presentation and management. Although most blast-related injuries (eg, fragmentation injuries from improvised explosive devices and standard military explosives) can be managed in a similar manner to typical penetrating or blunt traumatic injuries, injuries caused by the blast pressure wave itself cannot. The blast pressure wave exerts forces mainly at air–tissue interfaces within the body, and the pulmonary, gastrointestinal, and auditory systems are at greatest risk. Arterial air emboli arising from severe pulmonary injury can cause ischaemic complications—especially in the brain, heart, and intestinal tract. Attributable, in part, to the scene chaos that undoubtedly exists, poor triage and missed diagnosis of blast injuries are substantial concerns because injuries can be subtle or their presentation can be delayed. Management of these injuries can be a challenge, compounded by potentially conflicting treatment goals. This Seminar aims to provide a thorough overview of these unique primary blast injuries and their management.

View all citing articles on Scopus

: revision accepted September 15.

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Chest

Clinical Investigations in Critical CarePositive End-Expiratory Pressure Prevents the Loss of Respiratory Compliance During Low Tidal Volume Ventilation in Acute Lung Injury Patients

Study objective

Setting

Participants

Interventions

Measurements

Results

Conclusions

Section snippets

Patient Population

RESULTS

DISCUSSION

CONCLUSIONS

J Crit Care

Chest

Respir Physiol

Br J Anaesth

Ventilatory management of ARDS: can it affect the outcome

Intensive Care Med

PEEP, ARDS, and alveolar recruitment

Intensive Care Med

Re-targeting ventilatory objectives in adult respiratory distress syndrome: new treatment prospects-persistent questions

Am Rev Respir Dis

Permissive hypercapnic ventilation

Am J Respir Crit Care Med

Severe impairment in lung function induced by high peak airway pressure during mechanical ventilation: an experimental study

Am Rev Respir Dis

High inflation pressure pulmonary edema: respective effects of high airway pressure, high tidal volume, and positive end-expiratory pressure

Am Rev Respir Dis

Chest wall restriction limits high airway pressure-induced lung injury in young rabbits

J Appl Physiol

Acute respiratory failure in the adult (third of three parts)

N Engl J Med

Relation of volume history of lungs to respiratory mechanics in anesthetized dogs

J Appl Physiol

Impaired oxygenation in surgical patients during general anesthesia with controlled ventilation

N Engl J Med

Intermittent deep breaths and compliance during anesthesia in man

Anesthesiology

Clinical Investigations in Critical Care
Positive End-Expiratory Pressure Prevents the Loss of Respiratory Compliance During Low Tidal Volume Ventilation in Acute Lung Injury Patients