High positive end-Expiratory pressure renders spontaneous effort noninjurious

Caio C.A. Morais; Yukiko Koyama; Takeshi Yoshida; Glauco M. Plens; Susimeire Gomes; Cristhiano A.S. Lima; Ozires P.S. Ramos; Sérgio M. Pereira; Naomasa Kawaguchi; Hirofumi Yamamoto; Akinori Uchiyama; João B. Borges; Marcos F. Vidal Melo; Mauro R. Tucci; Marcelo B.P. Amato; Brian P. Kavanagh; Eduardo L.V. Costa; Yuji Fujino

doi:10.1164/rccm.201706-1244OC

High positive end-Expiratory pressure renders spontaneous effort noninjurious

Caio C.A. Morais, Yukiko Koyama, Takeshi Yoshida, Glauco M. Plens, Susimeire Gomes, Cristhiano A.S. Lima, Ozires P.S. Ramos, Sérgio M. Pereira, Naomasa Kawaguchi, Hirofumi Yamamoto, Akinori Uchiyama, João B. Borges, Marcos F. Vidal Melo, Mauro R. Tucci, Marcelo B.P. Amato, Brian P. Kavanagh, Eduardo L.V. Costa, Yuji Fujino

Research output: Contribution to journal › Article › peer-review

174 Scopus citations

Abstract

Rationale: In acute respiratory distress syndrome (ARDS), atelectatic solid-like lung tissue impairs transmission of negative swings in pleural pressure (Ppl) that result from diaphragmatic contraction. The localization of more negative Ppl proportionally increases dependent lung stretch by drawing gas either from other lung regions (e.g., nondependent lung [pendelluft]) or from the ventilator. Lowering the level of spontaneous effort and/or converting solid-like to fluid-like lung might render spontaneous effort noninjurious. Objectives: To determine whether spontaneous effort increases dependent lung injury, and whether such injury would be reduced by recruiting atelectatic solid-like lung with positive end-expiratory pressure (PEEP). Methods: Established models of severe ARDS (rabbit, pig) were used. Regional histology (rabbit), inflammation (positron emission tomography; pig), regional inspiratory Ppl (intrabronchial balloon manometry), and stretch (electrical impedance tomography; pig) were measured. Respiratory drive was evaluated in 11 patients with ARDS. Measurements and Main Results: Although injury during muscle paralysis was predominantly in nondependent and middle lung regions at low (vs. high) PEEP, strong inspiratory effort increased injury (indicated by positron emission tomography and histology) in dependent lung. Stronger effort (vs. muscle paralysis) caused local overstretch and greater tidal recruitment in dependent lung, where more negative Ppl was localized and greater stretch was generated. In contrast, high PEEP minimized lung injury by more uniformly distributing negative Ppl, and lowering the magnitude of spontaneous effort (i.e., deflection in esophageal pressure observed in rabbits, pigs, and patients). Conclusions: Strong effort increased dependent lung injury, where higher local lung stress and stretch was generated; effort-dependent lung injury was minimized by high PEEP in severe ARDS, which may offset need for paralysis.

Original language	English (US)
Pages (from-to)	1285-1296
Number of pages	12
Journal	American Journal of Respiratory and Critical Care Medicine
Volume	197
Issue number	10
DOIs	https://doi.org/10.1164/rccm.201706-1244OC
State	Published - May 15 2018
Externally published	Yes

Keywords

Acute respiratory distress syndrome
PEEP
Spontaneous breathing
Ventilator-induced lung injury

ASJC Scopus subject areas

Pulmonary and Respiratory Medicine
Critical Care and Intensive Care Medicine

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10.1164/rccm.201706-1244OC

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Morais, C. C. A., Koyama, Y., Yoshida, T., Plens, G. M., Gomes, S., Lima, C. A. S., Ramos, O. P. S., Pereira, S. M., Kawaguchi, N., Yamamoto, H., Uchiyama, A., Borges, J. B., Vidal Melo, M. F., Tucci, M. R., Amato, M. B. P., Kavanagh, B. P., Costa, E. L. V., & Fujino, Y. (2018). High positive end-Expiratory pressure renders spontaneous effort noninjurious. American Journal of Respiratory and Critical Care Medicine, 197(10), 1285-1296. https://doi.org/10.1164/rccm.201706-1244OC

Morais, CCA, Koyama, Y, Yoshida, T, Plens, GM, Gomes, S, Lima, CAS, Ramos, OPS, Pereira, SM, Kawaguchi, N, Yamamoto, H, Uchiyama, A, Borges, JB, Vidal Melo, MF, Tucci, MR, Amato, MBP, Kavanagh, BP, Costa, ELV & Fujino, Y 2018, 'High positive end-Expiratory pressure renders spontaneous effort noninjurious', American Journal of Respiratory and Critical Care Medicine, vol. 197, no. 10, pp. 1285-1296. https://doi.org/10.1164/rccm.201706-1244OC

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title = "High positive end-Expiratory pressure renders spontaneous effort noninjurious",

abstract = "Rationale: In acute respiratory distress syndrome (ARDS), atelectatic solid-like lung tissue impairs transmission of negative swings in pleural pressure (Ppl) that result from diaphragmatic contraction. The localization of more negative Ppl proportionally increases dependent lung stretch by drawing gas either from other lung regions (e.g., nondependent lung [pendelluft]) or from the ventilator. Lowering the level of spontaneous effort and/or converting solid-like to fluid-like lung might render spontaneous effort noninjurious. Objectives: To determine whether spontaneous effort increases dependent lung injury, and whether such injury would be reduced by recruiting atelectatic solid-like lung with positive end-expiratory pressure (PEEP). Methods: Established models of severe ARDS (rabbit, pig) were used. Regional histology (rabbit), inflammation (positron emission tomography; pig), regional inspiratory Ppl (intrabronchial balloon manometry), and stretch (electrical impedance tomography; pig) were measured. Respiratory drive was evaluated in 11 patients with ARDS. Measurements and Main Results: Although injury during muscle paralysis was predominantly in nondependent and middle lung regions at low (vs. high) PEEP, strong inspiratory effort increased injury (indicated by positron emission tomography and histology) in dependent lung. Stronger effort (vs. muscle paralysis) caused local overstretch and greater tidal recruitment in dependent lung, where more negative Ppl was localized and greater stretch was generated. In contrast, high PEEP minimized lung injury by more uniformly distributing negative Ppl, and lowering the magnitude of spontaneous effort (i.e., deflection in esophageal pressure observed in rabbits, pigs, and patients). Conclusions: Strong effort increased dependent lung injury, where higher local lung stress and stretch was generated; effort-dependent lung injury was minimized by high PEEP in severe ARDS, which may offset need for paralysis.",

keywords = "Acute respiratory distress syndrome, PEEP, Spontaneous breathing, Ventilator-induced lung injury",

author = "Morais, {Caio C.A.} and Yukiko Koyama and Takeshi Yoshida and Plens, {Glauco M.} and Susimeire Gomes and Lima, {Cristhiano A.S.} and Ramos, {Ozires P.S.} and Pereira, {S{\'e}rgio M.} and Naomasa Kawaguchi and Hirofumi Yamamoto and Akinori Uchiyama and Borges, {Jo{\~a}o B.} and {Vidal Melo}, {Marcos F.} and Tucci, {Mauro R.} and Amato, {Marcelo B.P.} and Kavanagh, {Brian P.} and Costa, {Eduardo L.V.} and Yuji Fujino",

note = "Publisher Copyright: Copyright {\textcopyright} 2018 by the American Thoracic Society.",

year = "2018",

month = may,

day = "15",

doi = "10.1164/rccm.201706-1244OC",

language = "English (US)",

volume = "197",

pages = "1285--1296",

journal = "American Journal of Respiratory and Critical Care Medicine",

issn = "1073-449X",

publisher = "American Thoracic Society",

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T1 - High positive end-Expiratory pressure renders spontaneous effort noninjurious

AU - Morais, Caio C.A.

AU - Koyama, Yukiko

AU - Yoshida, Takeshi

AU - Plens, Glauco M.

AU - Gomes, Susimeire

AU - Lima, Cristhiano A.S.

AU - Ramos, Ozires P.S.

AU - Pereira, Sérgio M.

AU - Kawaguchi, Naomasa

AU - Yamamoto, Hirofumi

AU - Uchiyama, Akinori

AU - Borges, João B.

AU - Vidal Melo, Marcos F.

AU - Tucci, Mauro R.

AU - Amato, Marcelo B.P.

AU - Kavanagh, Brian P.

AU - Costa, Eduardo L.V.

AU - Fujino, Yuji

PY - 2018/5/15

Y1 - 2018/5/15

N2 - Rationale: In acute respiratory distress syndrome (ARDS), atelectatic solid-like lung tissue impairs transmission of negative swings in pleural pressure (Ppl) that result from diaphragmatic contraction. The localization of more negative Ppl proportionally increases dependent lung stretch by drawing gas either from other lung regions (e.g., nondependent lung [pendelluft]) or from the ventilator. Lowering the level of spontaneous effort and/or converting solid-like to fluid-like lung might render spontaneous effort noninjurious. Objectives: To determine whether spontaneous effort increases dependent lung injury, and whether such injury would be reduced by recruiting atelectatic solid-like lung with positive end-expiratory pressure (PEEP). Methods: Established models of severe ARDS (rabbit, pig) were used. Regional histology (rabbit), inflammation (positron emission tomography; pig), regional inspiratory Ppl (intrabronchial balloon manometry), and stretch (electrical impedance tomography; pig) were measured. Respiratory drive was evaluated in 11 patients with ARDS. Measurements and Main Results: Although injury during muscle paralysis was predominantly in nondependent and middle lung regions at low (vs. high) PEEP, strong inspiratory effort increased injury (indicated by positron emission tomography and histology) in dependent lung. Stronger effort (vs. muscle paralysis) caused local overstretch and greater tidal recruitment in dependent lung, where more negative Ppl was localized and greater stretch was generated. In contrast, high PEEP minimized lung injury by more uniformly distributing negative Ppl, and lowering the magnitude of spontaneous effort (i.e., deflection in esophageal pressure observed in rabbits, pigs, and patients). Conclusions: Strong effort increased dependent lung injury, where higher local lung stress and stretch was generated; effort-dependent lung injury was minimized by high PEEP in severe ARDS, which may offset need for paralysis.

AB - Rationale: In acute respiratory distress syndrome (ARDS), atelectatic solid-like lung tissue impairs transmission of negative swings in pleural pressure (Ppl) that result from diaphragmatic contraction. The localization of more negative Ppl proportionally increases dependent lung stretch by drawing gas either from other lung regions (e.g., nondependent lung [pendelluft]) or from the ventilator. Lowering the level of spontaneous effort and/or converting solid-like to fluid-like lung might render spontaneous effort noninjurious. Objectives: To determine whether spontaneous effort increases dependent lung injury, and whether such injury would be reduced by recruiting atelectatic solid-like lung with positive end-expiratory pressure (PEEP). Methods: Established models of severe ARDS (rabbit, pig) were used. Regional histology (rabbit), inflammation (positron emission tomography; pig), regional inspiratory Ppl (intrabronchial balloon manometry), and stretch (electrical impedance tomography; pig) were measured. Respiratory drive was evaluated in 11 patients with ARDS. Measurements and Main Results: Although injury during muscle paralysis was predominantly in nondependent and middle lung regions at low (vs. high) PEEP, strong inspiratory effort increased injury (indicated by positron emission tomography and histology) in dependent lung. Stronger effort (vs. muscle paralysis) caused local overstretch and greater tidal recruitment in dependent lung, where more negative Ppl was localized and greater stretch was generated. In contrast, high PEEP minimized lung injury by more uniformly distributing negative Ppl, and lowering the magnitude of spontaneous effort (i.e., deflection in esophageal pressure observed in rabbits, pigs, and patients). Conclusions: Strong effort increased dependent lung injury, where higher local lung stress and stretch was generated; effort-dependent lung injury was minimized by high PEEP in severe ARDS, which may offset need for paralysis.

KW - Acute respiratory distress syndrome

KW - PEEP

KW - Spontaneous breathing

KW - Ventilator-induced lung injury

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High positive end-Expiratory pressure renders spontaneous effort noninjurious

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