Advertisement

Comparison of “Open Lung” Modes with Low Tidal Volumes in a Porcine Lung Injury Model

Published:November 15, 2010DOI:https://doi.org/10.1016/j.jss.2010.10.022

      Background

      Ventilator strategies that maintain an “open lung” have shown promise in treating hypoxemic patients. We compared three “open lung” strategies with standard of care low tidal volume ventilation and hypothesized that each would diminish physiologic and histopathologic evidence of ventilator induced lung injury (VILI).

      Materials and Methods

      Acute lung injury (ALI) was induced in 22 pigs via 5% Tween and 30-min of injurious ventilation. Animals were separated into four groups: (1) low tidal volume ventilation (LowVt -6 mL/kg); (2) high-frequency oscillatory ventilation (HFOV); (3) airway pressure release ventilation (APRV); or (4) recruitment and decremental positive-end expiratory pressure (PEEP) titration (RM+OP) and followed for 6 h. Lung and hemodynamic function was assessed on the half-hour. Bronchoalveolar lavage fluid (BALF) was analyzed for cytokines. Lung tissue was harvested for histologic analysis.

      Results

      APRV and HFOV increased PaO2/FiO2 ratio and improved ventilation. APRV reduced BALF TNF-α and IL-8. HFOV caused an increase in airway hemorrhage. RM+OP decreased SvO2, increased PaCO2, with increased inflammation of lung tissue.

      Conclusion

      None of the “open lung” techniques were definitively superior to LowVt with respect to VILI; however, APRV oxygenated and ventilated more effectively and reduced cytokine concentration compared with LowVt with nearly indistinguishable histopathology. These data suggest that APRV may be of potential benefit to critically ill patients but other “open lung” strategies may exacerbate injury.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Surgical Research
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Rubenfeld G.D.
        • Herridge M.S.
        Epidemiology and outcomes of acute lung injury.
        Chest. 2007; 131: 554
        • The Acute Respiratory Distress Syndrome Network
        Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.
        N Engl J Med. 2000; 342: 1301
        • Ranieri V.M.
        • Suter P.M.
        • 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
        • Halbertsma F.J.
        • Vaneker M.
        • Scheffer G.J.
        • et al.
        Cytokines and biotrauma in ventilator-induced lung injury: A critical review of the literature.
        Neth J Med. 2005; 63: 382
        • Suarez-Sipmann F.
        • Bohm S.
        • Lachmann B.
        Clinical perspectives of “the open lung concept”.
        Minerva Anestesiol. 1999; 65: 310
        • Suter P.M.
        Let us recruit the lung and keep an open mind.
        Intensive Care Med. 2000; 26: 491
        • Lachmann B.
        Open up the lung and keep the lung open.
        Intensive Care Med. 1992; 18: 319
        • Rotta A.T.
        • Gunnarsson B.
        • Fuhrman B.P.
        • et al.
        Comparison of lung protective ventilation strategies in a rabbit model of acute lung injury.
        Crit Care Med. 2001; 29: 2176
        • Imai Y.
        • Nakagawa S.
        • Ito Y.
        • et al.
        Comparison of lung protection strategies using conventional and high-frequency oscillatory ventilation.
        J Appl Physiol. 2001; 91: 1836
        • Wrigge H.
        • Zinserling J.
        • Neumann P.
        • et al.
        Spontaneous breathing improves lung aeration in oleic acid-induced lung injury.
        Anesthesiology. 2003; 99: 376
        • DiRocco J.D.
        • Pavone L.A.
        • Carney D.E.
        • et al.
        Dynamic alveolar mechanics in four models of lung injury.
        Intensive Care Med. 2006; 32: 140
        • Borges J.B.
        • Okamoto V.N.
        • Matos G.F.
        • et al.
        Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome.
        Am J Respir Crit Care Med. 2006; 174: 268
        • Kubiak B.D.
        • Albert S.P.
        • Gatto L.A.
        • et al.
        Peritoneal negative pressure therapy prevents multiple organ injury in a chronic porcine sepsis and ischemia/reperfusion model.
        Shock. 2010; 34: 525
        • Meade M.O.
        • Cook D.J.
        • Guyatt G.H.
        • et al.
        Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: A randomized controlled trial.
        Jama. 2008; 299: 637
        • Mercat A.
        • Richard J.C.
        • Vielle B.
        • et al.
        Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: A randomized controlled trial.
        Jama. 2008; 299: 646
        • Albert S.P.
        • DiRocco J.
        • Allen G.B.
        • et al.
        The role of time and pressure on alveolar recruitment.
        J Appl Physiol. 2009; 106: 757
        • Habashi N.M.
        Other approaches to open-lung ventilation: Airway pressure release ventilation.
        Crit Care Med. 2005; 33: S228
        • Myers T.R.
        • MacIntyre N.R.
        Respiratory controversies in the critical care setting. Does airway pressure release ventilation offer important new advantages in mechanical ventilator support?.
        Respir Care. 2007; 52 (discussion 458): 452
        • Wrigge H.
        • Zinserling J.
        • Neumann P.
        • et al.
        Spontaneous breathing with airway pressure release ventilation favors ventilation in dependent lung regions and counters cyclic alveolar collapse in oleic-acid-induced lung injury: A randomized controlled computed tomography trial.
        Crit Care. 2005; 9: R780
        • Conrad S.A.
        • Zhang S.
        • Arnold T.C.
        • et al.
        Protective effects of low respiratory frequency in experimental ventilator-associated lung injury.
        Crit Care Med. 2005; 33: 835
        • Steinberg J.
        • Schiller H.J.
        • Halter J.M.
        • et al.
        Tidal volume increases do not affect alveolar mechanics in normal lung but cause alveolar overdistension and exacerbate alveolar instability after surfactant deactivation.
        Crit Care Med. 2002; 30: 2675
        • Terragni P.P.
        • Rosboch G.
        • Tealdi A.
        • et al.
        Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome.
        Am J Respir Crit Care Med. 2007; 175: 160
        • Grasso S.
        • Stripoli T.
        • De Michele M.
        • et al.
        ARDSnet ventilatory protocol and alveolar hyperinflation: Role of positive end-expiratory pressure.
        Am J Respir Crit Care Med. 2007; 176: 761
        • Tschumperlin D.J.
        • Margulies S.S.
        Alveolar epithelial surface area-volume relationship in isolated rat lungs.
        J Appl Physiol. 1999; 86: 2026
        • Chan K.P.
        • Stewart T.E.
        • Mehta S.
        High-frequency oscillatory ventilation for adult patients with ARDS.
        Chest. 2007; 131: 1907
        • Ferguson N.D.
        • Chiche J.D.
        • Kacmarek R.M.
        • et al.
        Combining high-frequency oscillatory ventilation and recruitment maneuvers in adults with early acute respiratory distress syndrome: The Treatment with Oscillation and an Open Lung Strategy (TOOLS) Trial pilot study.
        Crit Care Med. 2005; 33: 479
        • Derdak S.
        • Mehta S.
        • Stewart T.E.
        • et al.
        High-frequency oscillatory ventilation for acute respiratory distress syndrome in adults: A randomized, controlled trial.
        Am J Respir Crit Care Med. 2002; 166: 801
        • Bollen C.W.
        • van Well G.T.
        • Sherry T.
        • et al.
        High frequency oscillatory ventilation compared with conventional mechanical ventilation in adult respiratory distress syndrome: A randomized controlled trial [ISRCTN24242669].
        Crit Care. 2005; 9: R430
        • Sedeek K.A.
        • Takeuchi M.
        • Suchodolski K.
        • et al.
        Determinants of tidal volume during high-frequency oscillation.
        Crit Care Med. 2003; 31: 227
        • Marini J.J.
        • Hotchkiss J.R.
        • Broccard A.F.
        Bench-to-bedside review: Microvascular and airspace linkage in ventilator-induced lung injury.
        Crit Care. 2003; 7: 435
        • Marini J.J.
        • Gattinoni L.
        Ventilatory management of acute respiratory distress syndrome: A consensus of two.
        Crit Care Med. 2004; 32: 250
        • Gattinoni L.
        • Caironi P.
        Refining ventilatory treatment for acute lung injury and acute respiratory distress syndrome.
        Jama. 2008; 299: 691
        • Downar J.
        • Mehta S.
        Bench-to-bedside review: High-frequency oscillatory ventilation in adults with acute respiratory distress syndrome.
        Crit Care. 2006; 10: 240
        • Grasso S.
        • Stripoli T.
        • Sacchi M.
        • et al.
        Inhomogeneity of lung parenchyma during the open lung strategy: A computed tomography scan study.
        Am J Respir Crit Care Med. 2009; 180: 415
        • Suarez-Sipmann F.
        • Bohm S.H.
        • Tusman G.
        • et al.
        Use of dynamic compliance for open lung positive end-expiratory pressure titration in an experimental study.
        Crit Care Med. 2007; 35: 214
        • Carvalho A.R.
        • Spieth P.M.
        • Pelosi P.
        • et al.
        Ability of dynamic airway pressure curve profile and elastance for positive end-expiratory pressure titration.
        Intensive Care Med. 2008; 34: 2291
        • Caramez M.P.
        • Kacmarek R.M.
        • Helmy M.
        • et al.
        A comparison of methods to identify open-lung PEEP.
        Intensive Care Med. 2009; 35: 740
        • Steinberg J.M.
        • Schiller H.J.
        • Halter J.M.
        • et al.
        Alveolar instability causes early ventilator-induced lung injury independent of neutrophils.
        Am J Respir Crit Care Med. 2004; 169: 57
        • Fessler H.E.
        • Derdak S.
        • Ferguson N.D.
        • et al.
        A protocol for high-frequency oscillatory ventilation in adults: Results from a roundtable discussion.
        Crit Care Med. 2007; 35: 1649