Hostname: page-component-cd9895bd7-8ctnn Total loading time: 0 Render date: 2024-12-24T14:01:32.506Z Has data issue: false hasContentIssue false
  • English
  • Français

Pressure–volume curve variations after a recruitment manoeuvre in acute lung injury/ARDS patients: implications for the understanding of the inflection points of the curve

Published online by Cambridge University Press:  19 April 2005

D. Pestaña ,
C. Hernández-Gancedo ,
C. Royo ,
H. Pérez-Chrzanowska  and
A. Criado
D. Pestaña
Affiliation:
Hospital Universitario La Paz, Servicio de Anestesia-Reanimación, Residencia General, Madrid, Spain
C. Hernández-Gancedo
Affiliation:
Hospital Universitario La Paz, Servicio de Anestesia-Reanimación, Residencia General, Madrid, Spain
C. Royo
Affiliation:
Hospital Universitario La Paz, Servicio de Anestesia-Reanimación, Residencia General, Madrid, Spain
H. Pérez-Chrzanowska
Affiliation:
Hospital Universitario La Paz, Servicio de Anestesia-Reanimación, Residencia General, Madrid, Spain
A. Criado
Affiliation:
Hospital Universitario La Paz, Servicio de Anestesia-Reanimación, Residencia General, Madrid, Spain
Get access

Abstract

Summary

Background and objective: Although the pressure–volume (P–V) curve has been proposed in the management of mechanically ventilated patients, its interpretation remains unclear. Our aim has been to study the variations of the P–V curve after a recruitment manoeuvre (RM). Our hypothesis was that the lower inflection point (LIP) represents the presence of compressive atelectases, so it should not change after lung recruitment, while the upper inflection point (UIP) reflects reabsorptive atelectases, and an effective recruitment should result in changes at this level.

Methods: Two P–V curves (quasi-static method) separated by an RM (40 cmH2O, two consecutive manoeuvres) were plotted in 35 postoperative patients with criteria of acute lung injury/acute respiratory distress syndrome (ARDS). LIP, UIP and expiratory inflection point (EIP) were defined as the first point where the curve consistently starts to separate from the line.

Results: One to six measurements were obtained per patient (73 procedures). Neither the lower nor the EIPs varied significantly after the RM (P = 0.11 and 0.35, respectively). An UIP was observed in 18 curves (25%) before the RM and disappeared on nine occasions after the recruitment. Similar results were obtained when first measurements only were analysed, and when the cause (pulmonary vs. extrapulmonary), severity of lung injury or duration of mechanical ventilation at first measurement were studied.

Conclusions: An RM does not modify the LIP significantly, but induces the disappearance of the UIP in 50% of the cases in which this point is found.

Keywords

ACUTE RESPIRATORY DISTRESS SYNDROMEMECHANICAL VENTILATION
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 22 , Issue 3 , March 2005 , pp. 175 - 180
Copyright
2005 European Society of Anaesthesiology

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Rouby JJ, Lu Q, Goldstein I. Selecting the right level of positive end-expiratory pressure in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2002; 165: 1182–1186.Google Scholar
Gattinoni L, Caironi P, Pelosi P, Goodman LR. What has computed tomography taught us about the acute respiratory distress syndrome? Am J Respir Crit Care Med 2001; 164: 1701–1711.Google Scholar
Amato MBP, Barbas CSV, Medeiros DM, et al. Effect of a protective ventilation strategy on mortality in the acute respiratory distress syndrome. New Engl J Med 1998; 338: 347–354.Google Scholar
Ranieri VM, Suter PM, Tortorella C, et al. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome. A randomized controlled trial. JAMA 1999; 282: 54–61.Google Scholar
Pestaña D, Hernãndez-Gancedo C, Royo C, et al. Adjusting positive end-expiratory pressure and tidal volume in acute respiratory distress syndrome according to the pressure–volume curve. Acta Anaesthesiol Scand 2003; 47: 326–334.Google Scholar
Malbouisson LM, Muller JC, Constantin JM, Lu Q, Puybasset L, Rouby JJ, the CT Scan ARDS Study Group. Computed tomography assessment of positive end-expiratory pressure-induced alveolar recruitment in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2001; 163: 1444–1450.Google Scholar
Mancini M, Zavala E, Mancebo J, et al. Mechanisms of pulmonary gas exchange improvement during a protective ventilatory strategy in acute respiratory distress syndrome. Am J Respir Crit Care Med 2001; 164: 1448–1453.Google Scholar
Hickling KG. Best compliance during a decremental, but not incremental, positive end-expiratory pressure trial is related to open-lung positive end-expiratory pressure. A mathematical model of acute respiratory distress syndrome lungs. Am J Respir Crit Care Med 2001; 163: 69–78.Google Scholar
Artigas A, Bernard GR, Carlet J, et al. The American–European Consensus Conference on ARDS, Part 2. Ventilatory, pharmacologic, supportive therapy, study design strategies and issues related to recovery and remodelling. Intensive Care Med 1998; 24: 378–398.Google Scholar
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: 1149–1156.Google Scholar
Richard JC, Maggiore SM, Jonson B, Mancebo J, Lemaire F, Brochard L. Influence of tidal volume on alveolar recruitment. Respective role of PEEP and a recruitment maneuver. Am J Respir Crit Care Med 2001; 163: 1609–1613.Google Scholar
Van der Kloot T, Blanch L, Youngblood M, et al. Recruitment maneuvers in three experimental models of acute lung injury. Effect on lung volume and gas exchange. Am J Respir Crit Care Med 2000; 161: 1485–1494.Google Scholar
Takeuchi M, Sedeek KA, Schettino GPP, Suchodolski K, Kacmarek RM. Peak pressure during volume history and pressure–volume curve measurement affects analysis. Am J Respir Crit Care Med 2001; 164: 1225–1230.Google Scholar
Crotti S, Mascheroni D, Caironi P, et al. Recruitment and derecruitment during acute respiratory failure. A clinical study. Am J Respir Crit Care Med 2001; 164: 131–140.Google Scholar
Gattinoni L, Pelosi P, Crotti S, Valenza F. Effects of positive end-expiratory pressure on regional distribution of tidal volume and recruitment in adult respiratory distress syndrome. Am J Respir Crit Care Med 1995; 151: 1807–1814.Google Scholar
Richard J-C, Brochard L, Vandelet P, et al. Respective effects of end-expiratory and end-inspiratory pressures on alveolar recruitment in acute lung injury. Crit Care Med 2003; 31: 89–92.Google Scholar
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: 795–801.Google Scholar
Hickling KG. The pressure–volume curve is greatly modified by recruitment. A mathematical model of ARDS lung. Am J Respir Crit Care Med 1998; 58: 194–202.Google Scholar
Jonson B, Richard JC, Straus C, Mancebo J, Lemaire F, Brochard L. Pressure–volume curves and compliance in acute lung injury. Evidence of recruitment above the lower inflection point. Am J Respir Crit Care Med 1999; 159: 1172–1178.Google Scholar
Pelosi P, Cadringher P, Bottino N, et al. Sigh in acute respiratory distress syndrome. Am J Respir Crit Care Med 1999; 159: 872–880.Google Scholar
Rimensberger PC, Cox PN, Frndova H, Bryan C. The open lung during small tidal volume ventilation: concepts of recruitment and ‘optimal’ positive end-expiratory pressure. Crit Care Med 1999; 27: 1946–1952.Google Scholar
Cakar N, Van der Kloot T, Youngblood M, Adams A, Nahum A. Oxygenation response to a recruitment maneuver during supine and prone positions in an oleic acid-induced lung injury model. Am J Respir Crit Care Med 2000; 61: 1949–1956.Google Scholar
Grasso S, Mascia L, Del Turco M, et al. Effects of recruiting maneuvers in patients with acute respiratory distress syndrome ventilated with protective ventilatory strategy. Anesthesiology 2002; 96: 795–802.Google Scholar
Lu Q, Capderou A, Cluzel P, et al. A computed tomographic scan assessment of endotracheal suctioning-induced bronchoconstriction in ventilated sheep. Am J Respir Crit Care Med 2000; 162: 1898–1904.Google Scholar
Villagrá A, Ochagavía A, Vatua S, et al. Recruitment maneuvers during lung protective ventilation in acute respiratory distress syndrome. Am J Respir Crit Care Med 2002; 165: 165–170.Google Scholar
Neumann P, Berglund JE, Fernández-Mondéjar E, Magnusson A, Hendestierna G. Dynamics of lung collapse and recruitment during prolonged breathing in porcine lung injury. J Appl Physiol 1998; 85: 1533–1543.Google Scholar
Vieillard-Baron A, Prin S, Schmitt JM, et al. Pressure–volume curves in acute respiratory distress syndrome. Clinical demonstration of the influence of expiratory flow limitation on the initial slope. Am J Respir Crit Care Med 2002; 165: 1107–1112.Google Scholar
Koutsoukou A, Bekos B, Sotiropoulou C, Koulouris NG, Roussos C, Milic-Emili J. Effects of positive end-expiratory pressure on gas exchange and expiratory flow limitation in adult respiratory distress syndrome. Crit Care Med 2002; 30: 1941–1949.Google Scholar
Martin-Lefèvre L, Ricard SD, Roupie E, Dreyfuss D, Saumon G. Significance of the changes in the respiratory system pressure–volume curve during acute lung injury in rats. Am J Respir Crit Care Med 2001; 164: 627–632.Google Scholar
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: 1082–1091.Google Scholar
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: 121–128.Google Scholar
Nagano O, Tokioka H, Ohta Y, Goto K, Katayama H, Hirakawa M. Inspiratory pressure–volume curves at different positive end-expiratory pressure levels in patients with ALI/ARDS. Acta Anaesthesiol Scand 2001; 45: 1255–1261.Google Scholar