Influence of respiratory rate and end-expiratory pressure variation on cyclic alveolar recruitment in an experimental lung injury model

Critical Care

Klaus Markstaller¹  Matthias David⁴  James E Baumgardner³  Amelie Elsaesser²  Klaus U Klein¹  Bastian Duenges⁴  Alexander Bentley⁴  Stefan Boehme¹  Erik K Hartmann⁴ 

[1] Department of Anaesthesia, General Critical Care Medicine and Pain Therapy, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria;Institute of Medical Biometry, Epidemiology and Informatics (IMBEI), Medical Center of the Johannes Gutenberg-University Mainz, 55131, Germany;Oscillogy LLC, 131 Milmont Ave, Folsom, Philadelphia, PA, 19033-3514, USA;Department of Anaesthesiology, Medical Center of the Johannes Gutenberg-University, Mainz 55131, Germany

关键词: varying shunt fractions;    respiratory- dependent paO 2 oscillations;    porcine model;    cyclic alveolar recruitment;    acute lung injury;   

Others  :  1093224
DOI  :  10.1186/cc11147

 received in 2011-10-04, accepted in 2012-01-16,  发布年份 2012

【 摘 要 】

Introduction

Cyclic alveolar recruitment/derecruitment (R/D) is an important mechanism of ventilator-associated lung injury. In experimental models this process can be measured with high temporal resolution by detection of respiratory-dependent oscillations of the paO₂ (ΔpaO₂). A previous study showed that end-expiratory collapse can be prevented by an increased respiratory rate in saline-lavaged rabbits. The current study compares the effects of increased positive end-expiratory pressure (PEEP) versus an individually titrated respiratory rate (RR_ind) on intra-tidal amplitude of Δ paO₂ and on average paO₂ in saline-lavaged pigs.

Methods

Acute lung injury was induced by bronchoalveolar lavage in 16 anaesthetized pigs. R/D was induced and measured by a fast-responding intra-aortic probe measuring paO₂. Ventilatory interventions (RR_ind (n = 8) versus extrinsic PEEP (n = 8)) were applied for 30 minutes to reduce Δ paO₂. Haemodynamics, spirometry and Δ paO₂ were monitored and the Ventilation/Perfusion distributions were assessed by multiple inert gas elimination. The main endpoints average and Δ paO₂ following the interventions were analysed by Mann-Whitney-U-Test and Bonferroni's correction. The secondary parameters were tested in an explorative manner.

Results

Both interventions reduced Δ paO₂. In the RR_ind group, ΔpaO₂ was significantly smaller (P < 0.001). The average paO₂ continuously decreased following RR_ind and was significantly higher in the PEEP group (P < 0.001). A sustained difference of the ventilation/perfusion distribution and shunt fractions confirms these findings. The RR_ind application required less vasopressor administration.

Conclusions

Different recruitment kinetics were found compared to previous small animal models and these differences were primarily determined by kinetics of end-expiratory collapse. In this porcine model, respiratory rate and increased PEEP were both effective in reducing the amplitude of paO₂ oscillations. In contrast to a recent study in a small animal model, however, increased respiratory rate did not maintain end-expiratory recruitment and ultimately resulted in reduced average paO₂ and increased shunt fraction.

【 授权许可】

   
2012 Hartmann et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

Figure 4.

【 参考文献 】

• [1]Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, Legall JR, Morris A, Spragg R: The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994, 149:818-824.
• [2]Phua J, Badia JR, Adhikari NK, Friedrich JO, Fowler RA, Singh JM, Scales DC, Stather DR, Li A, Jones A, Gattas DJ, Hallett D, Tomlinson G, Stewart TE, Ferguson ND: Has mortality from acute respiratory distress syndrome decreased over time?: A systematic review. Am J Respir Crit Care Med 2009, 179:220-227.
• [3]Zambon M, Vincent JL: Mortality rates for patients with acute lung injury/ARDS have decreased over time. Chest 2008, 133:1120-1127.
• [4]Esan A, Hess DR, Raoof S, George L, Sessler CN: Severe hypoxemic respiratory failure: part 1--ventilatory strategies. Chest 2010, 137:1203-1216.
• [5]Raoof S, Goulet K, Esan A, Hess DR, Sessler CN: Severe hypoxemic respiratory failure: part 2--nonventilatory strategies. Chest 2010, 137:1437-1448.
• [6]Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network N Engl J Med 2000, 342:1301-1308.
• [7]Wheeler AP, Bernard GR: Acute lung injury and the acute respiratory distress syndrome: a clinical review. Lancet 2007, 369:1553-1564.
• [8]Pinhu L, Whitehead T, Evans T, Griffiths M: Ventilator-associated lung injury. Lancet 2003, 361:332-340.
• [9]Bodenstein M, Wang H, Boehme S, Baumgardner JE, Duenges B, Vogt A, David M, Markstaller K: Observation of ventilation-induced Spo(2) oscillations in pigs: first step to noninvasive detection of cyclic recruitment of atelectasis? Exp Lung Res 2010, 36:270-276.
• [10]Shi C, Boehme S, Hartmann EK, Markstaller K: Novel technologies to detect atelectotrauma in the injured lung. Exp Lung Res 2011, 37:18-25.
• [11]Baumgardner JE, Markstaller K, Pfeiffer B, Doebrich M, Otto CM: Effects of respiratory rate, plateau pressure, and positive end-expiratory pressure on PaO2 oscillations after saline lavage. Am J Respir Crit Care Med 2002, 166:1556-1562.
• [12]Gattinoni L, Caironi P, Cressoni M, Chiumello D, Ranieri VM, Quintel M, Russo S, Patroniti N, Cornejo R, Bugedo G: Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med 2006, 354:1775-1786.
• [13]Briel M, Meade M, Mercat A, Brower RG, Talmor D, Walter SD, Slutsky AS, Pullenayegum E, Zhou Q, Cook D, Brochard L, Richard JC, Lamontagne F, Bhatnagar N, Stewart TE, Guyatt G: Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA 2010, 303:865-873.
• [14]Hickling KG: Reinterpreting the pressure-volume curve in patients with acute respiratory distress syndrome. Curr Opin Crit Care 2002, 8:32-38.
• [15]Markstaller K, Eberle B, Kauczor HU, Scholz A, Bink A, Thelen M, Heinrichs W, Weiler N: Temporal dynamics of lung aeration determined by dynamic CT in a porcine model of ARDS. Br J Anaesth 2001, 87:459-468.
• [16]Neumann P, Berglund JE, Fernandez Mondejar E, Magnusson A, Hedenstierna G: Dynamics of lung collapse and recruitment during prolonged breathing in porcine lung injury. J Appl Physiol 1998, 85:1533-1543.
• [17]Syring RS, Otto CM, Spivack RE, Markstaller K, Baumgardner JE: Maintenance of end-expiratory recruitment with increased respiratory rate after saline-lavage lung injury. J Appl Physiol 2007, 102:331-339.
• [18]Herweling A, Karmrodt J, Stepniak A, Fein A, Baumgardner JE, Eberle B, Markstaller K: A novel technique to follow fast PaO2 variations during experimental CPR. Resuscitation 2005, 65:71-78.
• [19]Duenges B, Vogt A, Bodenstein M, Wang H, Bohme S, Rohrig B, Baumgardner JE, Markstaller K: A comparison of micropore membrane inlet mass spectrometry-derived pulmonary shunt measurement with Riley shunt in a porcine model. Anesth Analg 2009, 109:1831-1835.
• [20]Evans JW, Wagner PD: Limits on VA/Q distributions from analysis of experimental inert gas elimination. J Appl Physiol 1977, 42:889-898.
• [21]Folgering H, Smolders FD, Kreuzer F: Respiratory oscillations of the arterial PO2 and their effects on the ventilatory controlling system in the cat. Pflugers Arch 1978, 375:1-7.
• [22]Pfeiffer B, Syring RS, Markstaller K, Otto CM, Baumgardner JE: The implications of arterial Po2 oscillations for conventional arterial blood gas analysis. Anesth Analg 2006, 102:1758-1764.
• [23]Williams EM, Viale JP, Hamilton RM, McPeak H, Sutton L, Hahn CE: Within-breath arterial PO2 oscillations in an experimental model of acute respiratory distress syndrome. Br J Anaesth 2000, 85:456-459.
• [24]Caironi P, Carlesso E, Gattinoni L: Radiological imaging in acute lung injury and acute respiratory distress syndrome. Semin Respir Crit Care Med 2006, 27:404-415.
• [25]Grasso S, Stripoli T, Sacchi M, Trerotoli P, Staffieri F, Franchini D, De Monte V, Valentini V, Pugliese P, Crovace A, Driessen B, Fiore T: Inhomogeneity of lung parenchyma during the open lung strategy: a computed tomography scan study. Am J Respir Crit Care Med 2009, 180:415-423.
• [26]Caironi P, Gattinoni L: How to monitor lung recruitment in patients with acute lung injury. Curr Opin Crit Care 2007, 13:338-343.
• [27]Klein KU, Boehme S, Hartmann EK, Duenges B, Markstaller K: PaO2-oscillations caused by cyclic recruitment can be detected in the microcirculation. In 2010 Annual Meeting of the American Society of Anesthesiologists. San Diego, CA, USA; 2010:A1511.
• [28]Orakcioglu B, Sakowitz OW, Neumann JO, Kentar MM, Unterberg A, Kiening KL: Evaluation of a novel brain tissue oxygenation probe in an experimental swine model. Neurosurgery 2010, 67:1716-1722. discussion 1722-1713
• [29]Wang HM, Bodenstein M, Markstaller K: Overview of the pathology of three widely used animal models of acute lung injury. Eur Surg Res 2008, 40:305-316.
• [30]Otto CM, Markstaller K, Kajikawa O, Karmrodt J, Syring RS, Pfeiffer B, Good VP, Frevert CW, Baumgardner JE: Spatial and temporal heterogeneity of ventilator-associated lung injury after surfactant depletion. J Appl Physiol 2008, 104:1485-1494.
• [31]Sinclair SE, Chi E, Lin HI, Altemeier WA: Positive end-expiratory pressure alters the severity and spatial heterogeneity of ventilator-induced lung injury: an argument for cyclical airway collapse. J Crit Care 2009, 24:206-211.
• [32]Baumgardner JE, Choi IC, Vonk-Noordegraaf A, Frasch HF, Neufeld GR, Marshall BE: Sequential V(A)/Q distributions in the normal rabbit by micropore membrane inlet mass spectrometry. J Appl Physiol 2000, 89:1699-1708.
• [33]Dunges B, Karmrodt J, Baumgardner JE, Markstaller K: Ventilation-perfusion distributions in the lungs. A novel technique for rapid measurement. Anaesthesist 2007, 56:612-616.
• [34]Klein KU, Boehme S, Hartmann EK, Szczyrba M, David M, Markstaller K, Engelhard K: A novel technique for monitoring of fast variations in brain oxygen tension using an uncoated fluorescence quenching probe (Foxy AL-300). J Neurosurg Anesthesiol 2011, 23:341-346.
• [35]Meier J, Habler O: Rational use of oxygen in anesthesiology and intensive care medicine. Anaesthesist 2011, 60:292-302.
• [36]Albert SP, DiRocco J, Allen GB, Bates JH, Lafollette R, Kubiak BD, Fischer J, Maroney S, Nieman GF: The role of time and pressure on alveolar recruitment. J Appl Physiol 2009, 106:757-765.
• [37]Karmrodt J, Bletz C, Yuan S, David M, Heussel CP, Markstaller K: Quantification of atelectatic lung volumes in two different porcine models of ARDS. Br J Anaesth 2006, 97:883-895.
• [38]Markstaller K, Kauczor HU, Weiler N, Karmrodt J, Doebrich M, Ferrante M, Thelen M, Eberle B: Lung density distribution in dynamic CT correlates with oxygenation in ventilated pigs with lavage ARDS. Br J Anaesth 2003, 91:699-708.