Skip to main content Accessibility help
×
Home

Derecruitment of the lung induced by stepwise lowering of positive end-expiratory pressure in patients with adult respiratory distress syndrome

  • E. De Robertis (a1), G. Servillo (a1), M. Pezza (a1), D. Viscidi (a1) and R. Tufano (a1)...

Extract

Summary

Background and objective: It has recently been suggested that recruitment proceeds far above the lower inflection point of the elastic pressure–volume (Pel/V) curve of the respiratory system. Accordingly, the value of the lower inflection point as a guide to set the positive end-expiratory pressure (PEEP) has been challenged. Our aim was to evaluate the derecruitment induced by stepwise decreasing PEEP levels.

Methods: Seven consecutive sedated and paralysed patients with acute respiratory distress syndrome were studied. Multiple Pel/V curves of the respiratory system were recorded at PEEP levels progressively decreasing in steps of 3.75 cmH2O from +15 to zero according to the principles of the low flow inflation method.

Results: Multiple Pel/V curves shifted towards lower volumes at decreasing PEEP. Dynamic compliance was higher for Pel/V curves recorded from lower PEEP levels. A high correlation (r = 0.99) was found between dynamic compliance and PEEP. The lower inflection point was on average 9.2 cmH2O. However, the transition between the lower segment and the linear part of the Pel/V curve was in general smooth to the eye. The upper inflection point was on average 23.8 cmH2O. A high correlation (r = 0.98) between the upper inflection point and PEEP was found.

Conclusions: The lower inflection point is a poor indicator of alveolar closure. The evaluation of derecruitment induced by a stepwise reduction in PEEP seems to be more useful than individual titration of PEEP and tidal volume in patients with adult respiratory distress syndrome.

Copyright

Corresponding author

Correspondence to: Edoardo De Robertis, Dipartimento di Anestesia e Rianimazione, Via S. Pansini, 5, 80131, Napoli, Italy. E-mail: ederober@unina.it; Tel: +39 081 746 3542; Fax: +39 081 545 6338

References

Hide All

References

Matamis D, Lemaire F, Harf A, Brun-Buisson C, Ansquer JC, Atlan G. Total respiratory pressure–volume curves in the adult respiratory distress syndrome. Chest 1984; 86: 5866.
Ranieri VM, Giuliani R, Fiore T, Dambrosio M, Milic-Emili J. Volume-pressure curve of the respiratory system predicts effects of PEEP in ARDS: ‘occlusion’ versus ‘constant flow’ technique. Am J Respir Crit Care Med 1994; 149: 1927.
Roupie E, Dambrosio M, Servillo G, et al. Titration of tidal volume and induced hypercapnia in acute respiratory distress syndrome. Am J Respir Crit Care Med 1995; 152: 121128.
Servillo G, Svantesson C, Beydon L, et al. Pressure–volume curves in acute respiratory failure. Automated low flow inflation versus occlusion. Am J Respir Crit Care Med 1997; 155: 16291636.
Servillo G, De Robertis E, Coppola M, Blasi F, Rossano F, Tufano R. Application of a computerised method to measure static pressure volume curve in acute respiratory distress syndrome. Intens Care Med 2000; 26: 1114.
Lemaire F. ARDS and PV curves: the inseparable duet? Intens Care Med 2000; 26: 12.
Jonson B, Svantesson C. Elastic pressure–volume curve: what information do they convey? Thorax 1999; 54: 8287.
Hickling KG. The pressure–volume curve is greatly modified by recruitment. A mathematical model of ARDS lungs. Am J Respir Crit Care Med 1998; 158: 194202.
Liu JM, De Robertis E, Blomquist S, Dahm PL, Svantesson C, Jonson B. Elastic pressure–volume curves of the respiratory system reveal a high tendency to lung collapse in young pigs. Intens Care Med 1999; 25: 11401146.
De Robertis E, Liu JM, Blomquist S, Dahm PL, Thorne J, Jonson B. Elastic properties of the lung and chest wall in young and adult healthy pigs. Eur Respir J 2001; 17: 703711.
Jonson B, Richard JC, Straus C, Mancebo J, Lemaire F, Brochard L. Pressure–volume curves in acute lung injury. Evidence of recruitment above the lower inflection point. Am J Respir Crit Care Med 1999; 159: 11721178.
Svantesson C, Drefeldt B, Sigurdsson S, Larsson A, Brochard L, Jonson B. A single computer-controlled mechanical insufflation allows determination of the pressure–volume relationship of the respiratory system. J Clin Monit 1999; 15: 916.
Sigurdson S, Svantesson C, Larsson A, Jonson B. Elastic pressure–volume curves indicate derecruitment after a single deep expiration in anaesthetised and muscle-relaxed healthy man. Acta Anaesthesiol Scand 2000; 44: 980984.
Bernard GR, Artigas A, Brigham KL, et al. The American–European consensus conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994; 149: 818824.
Murray JF, Matthay MA, Luce JM, Flick MR. An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis 1988; 138: 720723.
Servillo G, Coppola M, Blasi F, Tufano R. The measurement of the pressure–volume curves with computerized methods. Minerva Anesthesiol 2000; 66: 381385.
Svantesson C, Sigurdsson S, Larsson A, Jonson B. Effects of recruitment of collapsed lung units on the elastic pressure–volume relationship in anaesthetised healthy adults. Acta Anaesthesiol Scand 1998; 42: 11491156.
Gattinoni L, Pesenti A, Bombino M, et al. Relationships between lung computed tomographic density, gas exchange, and PEEP in acute respiratory failure. Anesthesiology 1988; 69: 824832.
Maggiore SM, Jonson B, Richard JC, Jaber S, Lemaire F, Brochard L. Alveolar derecruitment at decremental positive end-expiratory pressure levels in acute lung injury. Comparison with the lower inflection point, oxygenation and compliance. Am J Respir Crit Care Med 2001; 164: 795801.
Vieira SR, Puybasset L, Lu Q, et al. A scanographic assessment of pulmonary morphology in acute lung injury. Significance of the lower inflection point detected on the lung pressure–volume curve. Am J Respir Crit Care Med 1999; 159: 16121623.
Lachmann B. Open up the lung and keep the lung open. Intens Care Med 1992; 18: 319321.
Mergoni M, Martelli A, Volpi A, Primavera S, Zuccoli P, Rossi A. Impact of positive end-expiratory pressure on chest-wall and lung pressure–volume curve in acute respiratory failure. Am J Respir Crit Care Med 1997; 156: 846854.
Svantesson C, Sigurdsson S, Larson A, Jonson B. The contribution of the chest wall to the elastic pressure–volume curve of the total respiratory system. Intens Care Med 1998; 24: S95.
Ranieri VM, Brienza N, Santostasi S, et al. Impairment of lung and chest wall mechanics in patients with acute respiratory distress syndrome: role of abdominal distension. Am J Respir Crit Care Med 1997; 156: 10821091.
Richard JC, Maggiore SM, Jonson B, Mancebo J, Lemaire F, Brochard L. Influence of tidal volume on alveolar recruitment. Respective role of PEEP and recruitment maneuvre. Am J Respir Crit Care Med 2001; 163: 16091613.
Servillo G, De Robertis E, Maggiore S, Lemaire F, Brochard L, Tufano R. The upper inflection point of the pressure–volume curve. Influence of methodology and of different modes of ventilation. Intens Care Med 2002; 28: 842849.

Keywords

Related content

Powered by UNSILO

Derecruitment of the lung induced by stepwise lowering of positive end-expiratory pressure in patients with adult respiratory distress syndrome

  • E. De Robertis (a1), G. Servillo (a1), M. Pezza (a1), D. Viscidi (a1) and R. Tufano (a1)...

Metrics

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.