Increased Extravascular Lung Water Reduces the Efficacy of Alveolar Recruitment Maneuver in Acute Respiratory Distress Syndrome

Abstract

Introduction. In acute respiratory distress syndrome (ARDS) the recruitment maneuver (RM) is used to reexpand atelectatic areas of the lungs aiming to improve arterial oxygenation. The goal of our paper was to evaluate the response to RM, as assessed by measurements of extravascular lung water index (EVLWI) in ARDS patients. Materials and Methods. Seventeen adult ARDS patients were enrolled into a prospective study. Patients received protective ventilation. The RM was performed by applying a continuous positive airway pressure of 40 cm H2O for 40 sec. The efficacy of the RM was assessed 5 min later. Patients were identified as responders if PaO2/FiO2 increased by >20% above the baseline. EVLWI was assessed by transpulmonary thermodilution before the RM, and patients were divided into groups of low EVLWI (<10 mL/kg) and high EVLWI (≥10 mL/kg). Results. EVLWI was increased in 12 patients. Following RM, PaO2/FiO2 increased by 33 (4–65) % in the patients with low EVLWI, whereas those in the high EVLWI group experienced a change by only −1((−13)–(+5)) % (P = 0.035). Conclusion. In ARDS, the response to a recruitment maneuver might be related to the severity of pulmonary edema. In patients with incresed EVLWI, the recruitment maneuver is less effective.

Alveolar recruitment maneuver attenuates extravascular lung water in acute respiratory distress syndrome

“…This is consistent with other studies. [ 7 , 29 ] However, it is encouraging that the EVLWI and oxygenation (PaO 2 /FiO 2 ) improved after RM. The lack of a significant difference in the non-RM group can be explained by the efficacy of RM in reducing EVLWI and improving the PaO 2 /FiO 2 in ARDS.…”

“…In ARDS, accumulation of EVLW may result in lung tissue disruption, thus requiring higher PEEP to counteract the gravity-related lung collapse and consolidation. [ 7 ]…”

Protective ventilation from ICU to operating room: state of art and new horizons

“…The conflicts between the potential benefits of RM and high PEEP versus increased risk of 'static' lung injury resulting in VALI prompted Pelosi et al [66] to declare a new striking motto: 'Close down the lungs and keep them resting' 25 years after the original concept by Lachmann [67] (1992): 'Open up the lung and keep the lung open. ' The controversial effects of RM and high PEEP on pulmonary edema and systemic hemodynamics, the evidence of reduced injury and inflammation in the collapsed regions, the risk of static strain and overdistension, and even the emerging concept of 'permissive atelectases' support the position that we should personalize an 'open lung approach' only to the subsets of responders with significant and proven recruitment potential [68,69].…”

Diagnostics and intensive therapy of Acute Respiratory Distress Syndrome (Clinical guidelines of the Federation of Anesthesiologists and Reanimatologists of Russia)

“…Увеличение внесосудистой воды легких более 10 мл/кг у пациентов с ОРДС ассоциировано с меньшей рекрутабельностью альвеол, чем у пациентов с ВСВЛ менее 10 мл/кг, эффективность настройки РЕЕР и маневров рекрутирования альвеол у пациентов с ВСВЛ >10 мл/кг меньше, а риск гемодинамических нарушений выше; увеличение ВСВЛ более характерно для прямого повреждения легких [28,71,185,199,200].…”