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Respiratory and haemodynamic changes during decremental open lung positive end-expiratory pressure titration in patients with acute respiratory distress syndrome.
Crit Care. 2009; 13(2):R59.CC

Abstract

INTRODUCTION

To investigate haemodynamic and respiratory changes during lung recruitment and decremental positive end-expiratory pressure (PEEP) titration for open lung ventilation in patients with acute respiratory distress syndrome (ARDS) a prospective, clinical trial was performed involving 12 adult patients with ARDS treated in the surgical intensive care unit in a university hospital.

METHODS

A software programme (Open Lung Tool) incorporated into a standard ventilator controlled the recruitment (pressure-controlled ventilation with fixed PEEP at 20 cmH2O and increased driving pressures at 20, 25 and 30 cmH2O for two minutes each) and PEEP titration (PEEP lowered by 2 cmH2O every two minutes, with tidal volume set at 6 ml/kg). The open lung PEEP (OL-PEEP) was defined as the PEEP level yielding maximum dynamic respiratory compliance plus 2 cmH2O. Gas exchange, respiratory mechanics and central haemodynamics using the Pulse Contour Cardiac Output Monitor (PiCCO), as well as transoesophageal echocardiography were measured at the following steps: at baseline (T0); during the final recruitment step with PEEP at 20 cmH2O and driving pressure at 30 cmH2O, (T20/30); at OL-PEEP, following another recruitment manoeuvre (TOLP).

RESULTS

The ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) increased from T0 to TOLP (120 +/- 59 versus 146 +/- 64 mmHg, P < 0.005), as did dynamic respiratory compliance (23 +/- 5 versus 27 +/- 6 ml/cmH2O, P < 0.005). At constant PEEP (14 +/- 3 cmH2O) and tidal volumes, peak inspiratory pressure decreased (32 +/- 3 versus 29 +/- 3 cmH2O, P < 0.005), although partial pressure of arterial carbon dioxide (PaCO2) was unchanged (58 +/- 22 versus 53 +/- 18 mmHg). No significant decrease in mean arterial pressure, stroke volume or cardiac output occurred during the recruitment (T20/30). However, left ventricular end-diastolic area decreased at T20/30 due to a decrease in the left ventricular end-diastolic septal-lateral diameter, while right ventricular end-diastolic area increased. Right ventricular function, estimated by the right ventricular Tei-index, deteriorated during the recruitment manoeuvre, but improved at TOLP.

CONCLUSIONS

A standardised open lung strategy increased oxygenation and improved respiratory system compliance. No major haemodynamic compromise was observed, although the increase in right ventricular Tei-index and right ventricular end-diastolic area and the decrease in left ventricular end-diastolic septal-lateral diameter during the recruitment suggested an increased right ventricular stress and strain. Right ventricular function was significantly improved at TOLP compared with T0, although left ventricular function was unchanged, indicating effective lung volume optimisation.

Authors+Show Affiliations

Department of Anesthesiology and Critical Care Medicine, University Hospital Mannheim, Faculty of Medicine, University of Heidelberg, Theodor-Kutzer Ufer, 68165 Mannheim, Germany.No affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Clinical Trial
Journal Article

Language

eng

PubMed ID

19374751

Citation

Gernoth, Christian, et al. "Respiratory and Haemodynamic Changes During Decremental Open Lung Positive End-expiratory Pressure Titration in Patients With Acute Respiratory Distress Syndrome." Critical Care (London, England), vol. 13, no. 2, 2009, pp. R59.
Gernoth C, Wagner G, Pelosi P, et al. Respiratory and haemodynamic changes during decremental open lung positive end-expiratory pressure titration in patients with acute respiratory distress syndrome. Crit Care. 2009;13(2):R59.
Gernoth, C., Wagner, G., Pelosi, P., & Luecke, T. (2009). Respiratory and haemodynamic changes during decremental open lung positive end-expiratory pressure titration in patients with acute respiratory distress syndrome. Critical Care (London, England), 13(2), R59. https://doi.org/10.1186/cc7786
Gernoth C, et al. Respiratory and Haemodynamic Changes During Decremental Open Lung Positive End-expiratory Pressure Titration in Patients With Acute Respiratory Distress Syndrome. Crit Care. 2009;13(2):R59. PubMed PMID: 19374751.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Respiratory and haemodynamic changes during decremental open lung positive end-expiratory pressure titration in patients with acute respiratory distress syndrome. AU - Gernoth,Christian, AU - Wagner,Gerhard, AU - Pelosi,Paolo, AU - Luecke,Thomas, Y1 - 2009/04/17/ PY - 2009/01/07/received PY - 2009/03/06/revised PY - 2009/04/17/accepted PY - 2009/4/21/entrez PY - 2009/4/21/pubmed PY - 2009/9/9/medline SP - R59 EP - R59 JF - Critical care (London, England) JO - Crit Care VL - 13 IS - 2 N2 - INTRODUCTION: To investigate haemodynamic and respiratory changes during lung recruitment and decremental positive end-expiratory pressure (PEEP) titration for open lung ventilation in patients with acute respiratory distress syndrome (ARDS) a prospective, clinical trial was performed involving 12 adult patients with ARDS treated in the surgical intensive care unit in a university hospital. METHODS: A software programme (Open Lung Tool) incorporated into a standard ventilator controlled the recruitment (pressure-controlled ventilation with fixed PEEP at 20 cmH2O and increased driving pressures at 20, 25 and 30 cmH2O for two minutes each) and PEEP titration (PEEP lowered by 2 cmH2O every two minutes, with tidal volume set at 6 ml/kg). The open lung PEEP (OL-PEEP) was defined as the PEEP level yielding maximum dynamic respiratory compliance plus 2 cmH2O. Gas exchange, respiratory mechanics and central haemodynamics using the Pulse Contour Cardiac Output Monitor (PiCCO), as well as transoesophageal echocardiography were measured at the following steps: at baseline (T0); during the final recruitment step with PEEP at 20 cmH2O and driving pressure at 30 cmH2O, (T20/30); at OL-PEEP, following another recruitment manoeuvre (TOLP). RESULTS: The ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) increased from T0 to TOLP (120 +/- 59 versus 146 +/- 64 mmHg, P < 0.005), as did dynamic respiratory compliance (23 +/- 5 versus 27 +/- 6 ml/cmH2O, P < 0.005). At constant PEEP (14 +/- 3 cmH2O) and tidal volumes, peak inspiratory pressure decreased (32 +/- 3 versus 29 +/- 3 cmH2O, P < 0.005), although partial pressure of arterial carbon dioxide (PaCO2) was unchanged (58 +/- 22 versus 53 +/- 18 mmHg). No significant decrease in mean arterial pressure, stroke volume or cardiac output occurred during the recruitment (T20/30). However, left ventricular end-diastolic area decreased at T20/30 due to a decrease in the left ventricular end-diastolic septal-lateral diameter, while right ventricular end-diastolic area increased. Right ventricular function, estimated by the right ventricular Tei-index, deteriorated during the recruitment manoeuvre, but improved at TOLP. CONCLUSIONS: A standardised open lung strategy increased oxygenation and improved respiratory system compliance. No major haemodynamic compromise was observed, although the increase in right ventricular Tei-index and right ventricular end-diastolic area and the decrease in left ventricular end-diastolic septal-lateral diameter during the recruitment suggested an increased right ventricular stress and strain. Right ventricular function was significantly improved at TOLP compared with T0, although left ventricular function was unchanged, indicating effective lung volume optimisation. SN - 1466-609X UR - https://www.unboundmedicine.com/medline/citation/19374751/Respiratory_and_haemodynamic_changes_during_decremental_open_lung_positive_end_expiratory_pressure_titration_in_patients_with_acute_respiratory_distress_syndrome_ L2 - https://ccforum.biomedcentral.com/articles/10.1186/cc7786 DB - PRIME DP - Unbound Medicine ER -