Central hemodynamics during lung recruitment maneuvers at hypovolemia, normovolemia and hypervolemia. A study by echocardiography and continuous pulmonary artery flow measurements in lung-injured pigs

Nielsen, Jonas B; Nilsson, M.; Fredén, Filip; Hultman, Jan; Alström, Ulrica; Kjærgaard, Jesper; Hedenstierna, Göran; Larsson, Anders

doi:10.1007/s00134-006-0082-0

Cited by 66 publications

(26 citation statements)

References 29 publications

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“…29 Also, some animal studies raised concerns about hemodynamic intolerance of recruitment maneuvers. [30][31][32] In the present study we found no serious adverse hemodynamic effects, but that assessment was based on arterial blood pressure measurement, which may underestimate the effect on cardiac performance. 33…”

Section: Discussioncontrasting

confidence: 44%

Comparison of Optimal Positive End-Expiratory Pressure and Recruitment Maneuvers During Lung-Protective Mechanical Ventilation in Patients With Acute Lung Injury/Acute Respiratory Distress Syndrome

et al. 2009

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BACKGROUND: In patients with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), the use of alveolar-recruitment maneuvers to improve oxygenation is controversial. There is lack of standardization and lack of clinical studies to compare various recruitment maneuvers. Recruitment maneuvers are closely linked to the selection of positive end-expiratory pressure (PEEP), which is also a subject of debate. METHODS: With 12 intubated and mechanically ventilated patients with early ALI/ARDS we conducted a recruitment maneuver (sustained inflation at 40 cm H 2 O for 30 s), then set PEEP at 24 cm H 2 O, and then we reduced PEEP stepwise, by 4 cm H 2 O every 10 min. We kept the fraction of inspired oxygen (F IO 2) at 0.8. After each PEEP decrement step we measured P aO 2. We defined the "optimal" PEEP as the PEEP step above which P aO 2 decreased by > 20%. All the patients then underwent a period of ventilation on the same settings: tidal volume 6 mL/kg, PEEP at the level set by the physician before the experiment, plateau pressure < 30 cm H 2 O. Then each patient underwent 3 ventilation strategies, each applied for one hour: optimal PEEP alone; optimal PEEP plus one sustained inflation (40 cm H 2 O for 30 s); and optimal PEEP plus sigh breaths (ie, twice the baseline tidal volume, plateau pressure < 40 cm H 2 O) every 25 breaths. After the application of each PEEP strategy we measured arterial blood gas values and the static compliance of the respiratory system. RESULTS: The mean ؎ SD optimal PEEP was 12 ؎ 4 cm H 2 O. The measurements from the standardization periods were comparable between the 3 PEEP groups. In the optimal-PEEP-plus-sighs group the changes in P aO 2 (85 ؎ 96%) and static compliance (14 ؎ 20%) were significantly greater than in the 2 other groups. CONCLUSIONS: Sighs superimposed on lung-protective mechanical ventilation with optimal PEEP improved oxygenation and static compliance in patients with early ALI/ARDS.

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Section: Discussioncontrasting

confidence: 44%

Comparison of Optimal Positive End-Expiratory Pressure and Recruitment Maneuvers During Lung-Protective Mechanical Ventilation in Patients With Acute Lung Injury/Acute Respiratory Distress Syndrome

et al. 2009

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“…Nielsen et al . [51] tested the impact of RM in hypovolemia, normovolemia and hypervolemia. Lung RMs significantly decreased left ventricular end diastolic volume as well as cardiac output during hypovolemia.…”

Section: Discussionmentioning

confidence: 99%

Prone position and recruitment manoeuvre: the combined effect improves oxygenation

et al. 2011

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IntroductionAmong the various methods for improving oxygenation while decreasing the risk of ventilation-induced lung injury in patients with acute respiratory distress syndrome (ARDS), a ventilation strategy combining prone position (PP) and recruitment manoeuvres (RMs) can be practiced. We studied the effects on oxygenation of both RM and PP applied in early ARDS patients.MethodsWe conducted a prospective study. Sixteen consecutive patients with early ARDS fulfilling our criteria (ratio of arterial oxygen partial pressure to fraction of inspired oxygen (PaO2/FiO2) 98.3 ± 28 mmHg; positive end expiratory pressure, 10.7 ± 2.8 cmH2O) were analysed. Each patient was ventilated in both the supine position (SP) and the PP (six hours in each position). A 45 cmH2O extended sigh in pressure control mode was performed at the beginning of SP (RM1), one hour after turning to the PP (RM2) and at the end of the six-hour PP period (RM3).ResultsThe mean arterial oxygen partial pressure (PaO2) changes after RM1, RM2 and RM3 were 9.6%, 15% and 19%, respectively. The PaO2 improvement after a single RM was significant after RM3 only (P < 0.05). Improvements in PaO2 level and PaO2/FiO2 ratio were transient in SP but durable during PP. PaO2/FiO2 ratio peaked at 218 mmHg after RM3. PaO2/FiO2 changes were significant only after RM3 and in the pulmonary ARDS group (P = 0.008). This global strategy had a benefit with regard to oxygenation: PaO2/FiO2 ratio increased from 98.3 mmHg to 165.6 mmHg 13 hours later at the end of the study (P < 0.05). Plateau airway pressures decreased after each RM and over the entire PP period and significantly after RM3 (P = 0.02). Some reversible side effects such as significant blood arterial pressure variations were found when extended sighs were performed.ConclusionsIn our study, interventions such as a 45 cmH2O extended sigh during PP resulted in marked oxygenation improvement. Combined RM and PP led to the highest increase in PaO2/FiO2 ratio without major clinical side effects.

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“…Therefore the higher PaCO 2 with these settings might only be an artifact. It could also be caused by an increased alveolar dead space in overstretched lung regions, as well as compromised circulation due to the high airway pressures (31).…”

Section: Discussionmentioning

confidence: 99%

“…Second, hysteresis and shape of the PV curve might be due to other factors than pure lung and chest wall mechanics, e.g., blood volume shift and gas exchange (33). We did not compensate for gas exchange during the PV loop procedure because we estimated that its influence on the measured MH was <20 ml; the oxygen consumption in anesthetized, mechanically ventilated pigs of similar size as used in this study is about 140 ml/min, the duration of the whole procedure was <1 min, and the airway pressures used during the procedure would reduce pulmonary circulation and thus gas exchange (31, 34). Third, we have not measured chest wall compliance.…”

Section: Discussionmentioning

confidence: 99%

Maximal hysteresis: a new method to set positive end‐expiratory pressure in acute lung injury?

Koefoed-Nielsen

Andersen

Barklin

et al. 2008

Acta Anaesthesiol Scand

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Central hemodynamics during lung recruitment maneuvers at hypovolemia, normovolemia and hypervolemia. A study by echocardiography and continuous pulmonary artery flow measurements in lung-injured pigs

Cited by 66 publications

References 29 publications

Comparison of Optimal Positive End-Expiratory Pressure and Recruitment Maneuvers During Lung-Protective Mechanical Ventilation in Patients With Acute Lung Injury/Acute Respiratory Distress Syndrome

Comparison of Optimal Positive End-Expiratory Pressure and Recruitment Maneuvers During Lung-Protective Mechanical Ventilation in Patients With Acute Lung Injury/Acute Respiratory Distress Syndrome

Prone position and recruitment manoeuvre: the combined effect improves oxygenation

Maximal hysteresis: a new method to set positive end‐expiratory pressure in acute lung injury?

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