Individualized Positive End-expiratory Pressure and Regional Gas Exchange in Porcine Lung Injury. (April 2020)

• Record Type: Journal Article
• Authors: Muders, Thomas; Luepschen, Henning; Meier, Torsten; Reske, Andreas Wolfgang; Zinserling, Jörg; Kreyer, Stefan; Pikkemaat, Robert; Maripu, Enn; Leonhardt, Steffen; Hedenstierna, Göran; Putensen, Christian; Wrigge, Hermann
• Is Part Of: Anesthesiology. Volume 132:Number 4(2020)
• Publication Date: 2020-04
• Subjects: Anesthesiology -- Periodicals; Anesthetics -- Periodicals; Anesthesia -- Periodicals; 617.9605
• DOI: 10.1097/ALN.0000000000003151
• Languages: English
• ISSNs: 0003-3022

Abstract

Abstract : Background: In acute respiratory failure elevated intraabdominal pressure aggravates lung collapse, tidal recruitment, and ventilation inhomogeneity. Low positive end-expiratory pressure (PEEP) may promote lung collapse and intrapulmonary shunting, whereas high PEEP may increase dead space by inspiratory overdistension. The authors hypothesized that an electrical impedance tomography–guided PEEP approach minimizing tidal recruitment improves regional ventilation and perfusion matching when compared to a table-based low PEEP/no recruitment and an oxygenation-guided high PEEP/full recruitment strategy in a hybrid model of lung injury and elevated intraabdominal pressure. Methods: In 15 pigs with oleic acid–induced lung injury intraabdominal pressure was increased by intraabdominal saline infusion. PEEP was set in randomized order: (1) guided by a PEEP/inspired oxygen fraction table, without recruitment maneuver; (2) minimizing tidal recruitment guided by electrical impedance tomography after a recruitment maneuver; and (3) maximizing oxygenation after a recruitment maneuver. Single photon emission computed tomography was used to analyze regional ventilation, perfusion, and aeration. Primary outcome measures were differences in PEEP levels and regional ventilation/perfusion matching. Results: Resulting PEEP levels were different (mean ± SD) with (1) table PEEP: 11 ± 3 cm H2 O; (2) minimal tidal recruitment PEEP: 22 ± 3 cm H2 O; and (3) maximal oxygenation PEEP: 25 ± 4 cm H2 O; P < 0.001. Table PEEP without recruitment maneuver caused highest lung collapse (28 ± 11% vs. 5 ± 5% vs. 4 ± 4%; P < 0.001), shunt perfusion (3.2 ± 0.8 l/min vs. 1.0 ± 0.8 l/min vs. 0.7 ± 0.6 l/min; P < 0.001) and dead space ventilation (2.9 ± 1.0 l/min vs. 1.5 ± 0.7 l/min vs. 1.7 ± 0.8 l/min; P < 0.001). Although resulting in different PEEP levels, minimal tidal recruitment and maximal oxygenation PEEP, both following a recruitment maneuver, had similar effects on regional ventilation/perfusion matching. Conclusions: When compared to table PEEP without a recruitment maneuver, both minimal tidal recruitment PEEP and maximal oxygenation PEEP following a recruitment maneuver decreased shunting and dead space ventilation, and the effects of minimal tidal recruitment PEEP and maximal oxygenation PEEP were comparable. Abstract : In a porcine model of induced acute lung injury, with increased abdominal pressure caused by intraperitoneal saline infusion, using a crossover design, tracheostomized animals were ventilated using: (1) positive end-expiratory pressure (PEEP) table–based low PEEP without lung recruitment; (2) minimal tidal recruitment PEEP guided by electrical impedance tomography with recruitment; and (3) maximal oxygenation PEEP with recruitment. Using a PEEP table and no recruitment, compared with recruitment and either minimal tidal recruitment PEEP or maximal oxygenation PEEP, resulted in less delivered PEEP, and more lung collapse and regional ventilation/perfusion mismatch. The latter two methods had comparable results.Supplemental Digital Content is available in the text.