Matching positive end-expiratory pressure to intra-abdominal pressure prevents end-expiratory lung volume decline in a pig model of intra-abdominal hypertension*

Regli, Adrian; Chakera, Jakob; Keulenaer, Bart L. De; Roberts, Brigit; Noffsinger, Bill; Singh, Bhajan; Heerden, Peter Vernon van

doi:10.1097/ccm.0b013e31824e0e80

Cited by 37 publications

(60 citation statements)

References 35 publications

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“…IAH has been reported to reduce lung volumes and increase trans-diaphragmatic pressures, inspiratory airway pressures and chest wall elastance [8,10-13]. …”

Section: Introductionmentioning

confidence: 99%

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Matching positive end-expiratory pressure to intra-abdominal pressure improves oxygenation in a porcine sick lung model of intra-abdominal hypertension

et al. 2012

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IntroductionIntra-abdominal hypertension (IAH) causes atelectasis, reduces lung volumes and increases respiratory system elastance. Positive end-expiratory pressure (PEEP) in the setting of IAH and healthy lungs improves lung volumes but not oxygenation. However, critically ill patients with IAH often suffer from acute lung injury (ALI). This study, therefore, examined the respiratory and cardiac effects of positive end-expiratory pressure in an animal model of IAH, with sick lungs.MethodsNine pigs were anesthetized and ventilated (48 +/- 6 kg). Lung injury was induced with oleic acid. Three levels of intra-abdominal pressure (baseline, 18, and 22 mmHg) were randomly generated. At each level of intra-abdominal pressure, three levels of PEEP were randomly applied: baseline (5 cmH2O), moderate (0.5 × intra-abdominal pressure), and high (1.0 × intra-abdominal pressure). We measured end-expiratory lung volumes, arterial oxygen levels, respiratory mechanics, and cardiac output 10 minutes after each new IAP and PEEP setting.ResultsAt baseline PEEP, IAH (22 mmHg) decreased oxygen levels (-55%, P <0.001) and end-expiratory lung volumes (-45%, P = 0.007). At IAP of 22 mmHg, moderate and high PEEP increased oxygen levels (+60%, P = 0.04 and +162%, P <0.001) and end-expiratory lung volume (+44%, P = 0.02 and +279%, P <0.001) and high PEEP reduced cardiac output (-30%, P = 0.04). Shunt and dead-space fraction inversely correlated with oxygen levels and end-expiratory lung volumes. In the presence of IAH, lung, chest wall and respiratory system elastance increased. Subsequently, PEEP decreased respiratory system elastance by decreasing chest wall elastance.ConclusionsIn a porcine sick lung model of IAH, PEEP matched to intra-abdominal pressure led to increased lung volumes and oxygenation and decreased chest wall elastance shunt and dead-space fraction. High PEEP decreased cardiac output. The study shows that lung injury influences the effects of IAH and PEEP on oxygenation and respiratory mechanics. Our findings support the application of PEEP in the setting of acute lung injury and IAH.

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“…IAH has been reported to reduce lung volumes and increase trans-diaphragmatic pressures, inspiratory airway pressures and chest wall elastance [8,10-13]. …”

Section: Introductionmentioning

confidence: 99%

“…Furthermore, we previously were able to show that the application of higher than usual PEEP levels that were adapted to the degree of IAP was able to reverse lung volumes in a healthy porcine lung model of IAH [10,13]. …”

Section: Introductionmentioning

confidence: 99%

Matching positive end-expiratory pressure to intra-abdominal pressure improves oxygenation in a porcine sick lung model of intra-abdominal hypertension

et al. 2012

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“…The average BMI of the subjects in these 4 groups was relatively low ( The increased intraabdominal pressure caused by pneumoperitoneum, and not solely the BMI of the subjects in the Almarakbi et al 36 study, potentially contributed to the need for recruitment maneuvers and PEEP to optimally improve lung function, because an increase in intra-abdominal pressure leads to a decrease in lung volume and an increased need for PEEP. 45 To further support this possibility that pneumoperitoneum contributes significantly to pleural pressure, Futier et al 42 show 2 ) received VC-CMV with 10 cm H 2 O of PEEP, 6 mL/kg predicted body weight of V T , and 2 recruitment maneuvers: one after the induction of pneumoperitoneum and another after exsufflation. The recruitment maneuver consisted of a 40-s inspiratory hold at 40 cm H 2 O CPAP.…”

Section: Recruitment Maneuversmentioning

confidence: 99%

Respiratory Management of Perioperative Obese Patients

et al. 2016

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SummaryWith a rising incidence of obesity in the United States, anesthesiologists are faced with a larger volume of obese patients coming to the operating room as well as obese patients with ever-larger body mass indices (BMIs). While there are many cardiovascular and endocrine issues that clinicians must take into account when caring for the obese patient, one of the most prominent concerns of the anesthesiologist in the perioperative setting should be the status of the lung. Because the pathophysiology of reduced lung volumes in the obese patient differs from that of the ARDS patient, the best approach to keeping the obese patient's lung open and adequately ventilated during mechanical ventilation is unique. Although strong evidence and research are lacking regarding how to best ventilate the obese surgical patient, we aim with this review to provide an assessment of the small amount of research that has been conducted and the pathophysiology we believe influences the apparent results. We will provide a basic overview of the anatomy and pathophysiology of the obese respiratory system and review studies concerning pre-, intra-, and postoperative respiratory care. Our focus in this review centers on the best approach to keeping the lung recruited through the prevention of compression atelectasis and the maintaining of physiological lung volumes. We recommend the use of PEEP via noninvasive ventilation (NIV) before induction and endotracheal intubation, the use of both PEEP and periodic recruitment maneuvers during mechanical ventilation, and the use of PEEP via NIV after extubation. It is our hope that by studying the underlying mechanisms that make ventilating obese patients so difficult, future research can be better tailored to address this increasingly important challenge to the field of anesthesia.

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“…Research suggests the optimal ventilator management of patients with ARDS and IAH should include the following: (a) monitoring of IAP, P es , and hemodynamic parameters; (b) ventilation with protective V T , recruitment maneuvers, and PEEP set according to the “best” compliance of the respiratory system or lung; (c) deep sedation (with or without neuromuscular blockade in severe ARDS); and (d) an open abdomen in selected patients with severe ACS [44]. Previous experimental studies investigating the optimization of mechanical ventilation during IAH were performed with controlled mechanical ventilation and mainly focused on respiratory mechanics, partitioned into its lung and chest wall components, and/or gas exchange in healthy and diseased animals [31,32]; others yet focused on hemodynamics [45,46]. …”

Section: Discussionmentioning

confidence: 99%

Effects of pressure support and pressure-controlled ventilation on lung damage in a model of mild extrapulmonary acute lung injury with intra-abdominal hypertension

Santos

Moraes

et al. 2017

PLoS ONE

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Intra-abdominal hypertension (IAH) may co-occur with the acute respiratory distress syndrome (ARDS), with significant impact on morbidity and mortality. Lung-protective controlled mechanical ventilation with low tidal volume and positive end-expiratory pressure (PEEP) has been recommended in ARDS. However, mechanical ventilation with spontaneous breathing activity may be beneficial to lung function and reduce lung damage in mild ARDS. We hypothesized that preserving spontaneous breathing activity during pressure support ventilation (PSV) would improve respiratory function and minimize ventilator-induced lung injury (VILI) compared to pressure-controlled ventilation (PCV) in mild extrapulmonary acute lung injury (ALI) with IAH. Thirty Wistar rats (334±55g) received Escherichia coli lipopolysaccharide intraperitoneally (1000μg) to induce mild extrapulmonary ALI. After 24h, animals were anesthetized and randomized to receive PCV or PSV. They were then further randomized into subgroups without or with IAH (15 mmHg) and ventilated with PCV or PSV (PEEP = 5cmH2O, driving pressure adjusted to achieve tidal volume = 6mL/kg) for 1h. Six of the 30 rats were used for molecular biology analysis and were not mechanically ventilated. The main outcome was the effect of PCV versus PSV on mRNA expression of interleukin (IL)-6 in lung tissue. Regardless of whether IAH was present, PSV resulted in lower mean airway pressure (with no differences in peak airway or peak and mean transpulmonary pressures) and less mRNA expression of biomarkers associated with lung inflammation (IL-6) and fibrogenesis (type III procollagen) than PCV. In the presence of IAH, PSV improved oxygenation; decreased alveolar collapse, interstitial edema, and diffuse alveolar damage; and increased expression of surfactant protein B as compared to PCV. In this experimental model of mild extrapulmonary ALI associated with IAH, PSV compared to PCV improved lung function and morphology and reduced type 2 epithelial cell damage.

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Matching positive end-expiratory pressure to intra-abdominal pressure prevents end-expiratory lung volume decline in a pig model of intra-abdominal hypertension*

Cited by 37 publications

References 35 publications

Matching positive end-expiratory pressure to intra-abdominal pressure improves oxygenation in a porcine sick lung model of intra-abdominal hypertension

Matching positive end-expiratory pressure to intra-abdominal pressure improves oxygenation in a porcine sick lung model of intra-abdominal hypertension

Respiratory Management of Perioperative Obese Patients

Effects of pressure support and pressure-controlled ventilation on lung damage in a model of mild extrapulmonary acute lung injury with intra-abdominal hypertension

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