Prolonged recruitment manoeuvre improves lung function with less ultrastructural damage in experimental mild acute lung injury
Introduction
Cyclic opening and closing of atelectatic alveoli and distal small airways with tidal ventilation is a basic mechanism often leading to ventilator-induced lung injury (VILI) (Dreyfuss and Saumon, 1998). However, atelectatic lung units must be initially opened for PEEP to be effective (Lachmann, 1992). Therefore, lung recruitment manoeuvres (RMs) are used to open up collapsed lung, while PEEP counteracts alveolar derecruitment during low tidal volume ventilation (Crotti et al., 2001, Pelosi et al., 2001).
The response to RMs varies according to the nature, phase, and/or extent of the lung injury (Riva et al., 2008), pre-existing and post procedural patterns of tidal volume and PEEP, number of RMs performed (Richard et al., 2001), and characteristics of recruitment techniques (Borges et al., 2006). Definite guidelines for RM methodology have not been established. The most commonly used RM is the sustained inflation (SI), with rapid high recruitment pressure at 40 cmH2O applied for up to 60 s (Lapinsky et al., 1999, Rimensberger et al., 1999, Kloot et al., 2000, Grasso et al., 2009). SI has been shown to be effective in reducing lung atelectasis (Farias et al., 2005), improving oxygenation (Lapinsky et al., 1999) and respiratory mechanics (Farias et al., 2005, Riva et al., 2008), and preventing endotracheal suctioning-induced alveolar derecruitment (Maggiore et al., 2003). However, other studies have shown that SI might be less effective (Villagrá et al., 2002), short-lived (Brower et al., 2003, Oczenski et al., 2004), associated with circulatory side-effects (Oczenski et al., 2004, Odenstedt et al., 2005a), increased risk of baro/volutrauma (Boussarsar et al., 2002, Lim et al., 2003, Meade et al., 2008), and reduced net alveolar fluid clearance (Constantin et al., 2007), resulting in worsened oxygenation (Musch et al., 2004) and severe clinical consequences (Meade et al., 2008). Furthermore, in preterm lambs, a few sustained inflations, when forced immediately at birth, may have compromises the effect of subsequent surfactant rescue treatment (Björklund et al., 1997).
Several other types of RMs have been suggested to achieve lung volume expansion with less traumatic methods, such as: 1) prolonged lower pressure recruitment manoeuvre with PEEP elevation to 15 cmH2O and end-inspiratory pauses for 7 s twice per minute during 15 min (Odenstedt et al., 2005b), 2) incrementally increased PEEP limiting the maximum inspiratory pressure (Lim et al., 2001), and 3) pressure-controlled ventilation (PCV) applied with escalating PEEP and constant driving pressure (Villagrá et al., 2002, Fujino et al., 2001, Medoff et al., 2000). Nevertheless, during these RMs PEEP increased progressively achieving higher PEEP levels, which may have yielded lung parenchyma injury.
Different techniques of RMs have been proposed as an adjunct to mechanical ventilation and differences among them may be related to the following parameters: the level of recruiting pressure, the duration over which it is maintained, the pattern applied to accomplish recruitment, and the post-RM PEEP (Lapinsky et al., 1999, Rimensberger et al., 1999, Cakar et al., 2000, Kloot et al., 2000, Medoff et al., 2000, Fujino et al., 2001, Lim et al., 2001, Grasso et al., 2002, Villagrá et al., 2002, Marini, 2008). So far, however, the benefits and possible risks of RMs have not been clearly established.
Therefore, we hypothesized that using a prolonged recruitment manoeuvre (PRM), maintaining a fixed higher PEEP level and progressively increasing the positive inspiratory pressure, lung parenchyma stress and strain could be minimized, with less negative hemodynamic effects.
The aim of the present study was to compare the effects between a PRM, using pressure-controlled ventilation with a fixed PEEP level and a progressive increase in positive inspiratory pressure, and sustained inflation on arterial blood gases, lung mechanics and histology (light and electron microscopy), and mRNA expression of tumour necrosis factor (TNF)-α, interleukin (IL)-6, interferon (INF)-γ, transforming growth factor (TGF)-β1, TGF-β2, and type III procollagen (PCIII) in lung tissue in an experimental paraquat-induced mild ALI.
Section snippets
Methods
This study was approved by the Ethics Committee of the Carlos Chagas Filho Institute of Biophysics, Health Sciences Centre, and Federal University of Brazil. All animals received care in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the U.S. National Academy of Sciences.
Results
Mean arterial pressure was maintained stable (65–95 mmHg) during the RM and throughout the experiments.
PaO2 and pH were lower while PaCO2 was higher in ALI than in C, independent of ventilatory strategy (P < 0.05) (Table 1). In ALI, the percentage of increase of PaO2 from BASELINE to END was 13% (p = 0.01) and 44% (p < 0.001) after SI and PRM, respectively (Table 2). PaCO2 significantly decreased (21%, p = 0.007) and pH increased (p = 0.02) only in PRM group with no significant changes in SI (Table 1).
Discussion
In the present experimental model of mild ALI, a PRM, using pressure-controlled ventilation and progressively increased driving pressures with a fixed PEEP of 15 cmH2O, was compared to conventional rapid high pressure recruitment manoeuvre (SI) and showed an improvement in gas-exchange and Est,L, with less alveolar collapse, lung epithelial cell apoptosis, alveolar epithelial and endothelial cell damage, pulmonary inflammation, and PCIII mRNA expression in lung tissue.
ALI was induced by
Acknowledgements
The authors would like to express their gratitude to Mr. Andre Benedito da Silva for animal care, Mrs. Jaqueline Lima do Nascimento for her skilful technical assistance during the experiments, Mrs. Ana Lucia Neves da Silva for her help with microscopy, and Mrs. Moira Elizabeth Schöttler for assistance in editing the manuscript.
Supported by: Centres of Excellence Program (PRONEX-FAPERJ), Brazilian Council for Scientific and Technological Development (CNPq), Carlos Chagas Filho, Rio de Janeiro
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