Lung recruitment can improve oxygenation in patients ventilated in continuous positive airway pressure/pressure support mode

András Lovas, Márton Ferenc Németh, Domonkos Trásy, Zsolt Molnár, András Lovas, Márton Ferenc Németh, Domonkos Trásy, Zsolt Molnár

Abstract

Background: Recruitment maneuvers are often used in critical care patients with hypoxemic respiratory failure. Although continuous positive airway pressure/pressure support (CPAP/PS) ventilation is a frequently used approach, but whether lung recruitment also improves oxygenation in spontaneously breathing patients has not been investigated yet. The primary objective was to analyze the effect of recruitment maneuver on oxygenation in patients ventilated in CPAP/PS mode.

Methods: Following baseline measurements PEEP was increased by 5 cmH2O. Recruitment maneuver was applied for 40 s with 40 cmH2O of PS. Measurements of the difference in PaO2/FiO2 and airway parameters measured by the ventilator were recorded immediately after recruitment then 15 and 30 min later. Thirty patients ventilated in CPAP/PS mode with a PEEP ≥5 cmH2O were enrolled in this prospective, observational study if their PaO2/FiO2 ratio was <300 mmHg or required an FiO2 >0.5.

Results: Following recruitment maneuver patients were considered as non-responders (NR, n = 15) if difference of PaO2/FiO2 <20% and responders (R, n = 15) if difference of PaO2/FiO2 ≥20%. In the NR-group, PaO2/FiO2 decreased non-significantly from baseline: median [interquartile], PaO2/FiO2 = 176 [120-186] vs. after recruitment: 169 [121-182] mmHg, P = 0.307 while in the R-group there was significant improvement: 139 [117-164] vs. 230 [211-323] mmHg, P = 0.01. At the same time points, dead space to tidal volume ratio (Vds/Vte) significantly increased in the NR-group Vds/Vte = 32 [27-37] vs. 36 [25-42]%, P = 0.013 but no significant change was observed in the R-group: 26 [22-34] vs. 27 [24-33]%, P = 0.386.

Conclusion: Recruitment maneuver improved PaO2/FiO2 ratio by ≥20% in 50% of patients ventilated in CPAP/PS mode.

Keywords: CPAP ventilation; capnography; lung compliance; lung recruitment; positive end-expiratory pressure.

Figures

Figure 1
Figure 1
Changes in PaO2/FiO2. t0, baseline measurements; t1, increasing PEEP by 5 cmH2O; t2, after recruitment; t3 and t4, 15 and 30 min after recruitment. *Significant difference as compared to baseline measurements, P < 0.05.
Figure 2
Figure 2
Changes in PaO2/FiO2 and dynamic compliance after recruitment maneuver as compared to baseline parameters. Crs, dynamic compliance, Sens., sensitivity; Spec., specificity.

References

    1. Eastwood G, Bellomo R, Bailey M, Taori G, Pilcher D, Young P, et al. Arterial oxygen tension and mortality in mechanically ventilated patients. Intensive Care Med (2012) 38:91–8.10.1007/s00134-011-2419-6
    1. Briel M, Meade M, Mercat A, Brower RG, Talmor D, Walter SD, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA (2010) 303:865–73.10.1001/jama.2010.218
    1. Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med (2013) 368:2159–68.10.1056/NEJMoa1214103
    1. Suzumura EA, Figueiró M, Normilio-Silva K, Laranjeira L, Oliveira C, Buehler AM, et al. Effects of alveolar recruitment maneuvers on clinical outcomes in patients with acute respiratory distress syndrome: a systematic review and meta-analysis. Intensive Care Med (2014) 40:1227–40.10.1007/s00134-014-3413-6
    1. Cortés I, Peñuelas O, Esteban A. Acute respiratory distress syndrome: evaluation and management. Minerva Anestesiol (2012) 78:343–57.
    1. Vimlati L, Kawati R, Hedenstierna G, Larsson A, Lichtwarck-Aschoff M. Spontaneous breathing improves shunt fraction and oxygenation in comparison with controlled ventilation at a similar amount of lung collapse. Anesth Analg (2011) 113:1089–95.10.1213/ANE.0b013e31822ceef8
    1. Lachman B. Open up the lung and keep the lung open. Intensive Care Med (1992) 18:319–2110.1007/BF01694358
    1. Gattinoni L, Caironi P, Cressoni M, Chiumello D, Ranieri VM, Quintel M, et al. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med (2006) 354:1775–86.10.1056/NEJMoa052052
    1. Sassoon CS, Zhu E, Caiozzo VJ. Assist-control mechanical ventilation attenuates ventilator-induced diaphragmatic dysfunction. Am J Respir Crit Care Med (2004) 170:626–32.10.1164/rccm.200401-042OC
    1. Putensen C, Muders T, Varelmann D, Wrigge H. The impact of spontaneous breathing during mechanical ventilation. Curr Opin Crit Care (2006) 12:13–810.1097/01.ccx.0000198994.37319.60
    1. Cammarota G, Vaschetto R, Turucz E, Dellapiazza F, Colombo D, Blando C, et al. Influence of lung collapse distribution on the physiologic response to recruitment maneuvers during noninvasive continuous positive airway pressure. Intensive Care Med (2011) 37:1095–102.10.1007/s00134-011-2239-8
    1. Brochard L, Martin GS, Blanch L, Pelosi P, Belda FJ, Jubran A, et al. Clinical review: respiratory monitoring in the ICU – a consensus of 16. Crit Care (2012) 16:219.10.1186/cc11146
    1. Murray JF, Matthay MA, Luce JM, Flick MR. An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis (1988) 138:720–310.1164/ajrccm/138.3.720
    1. Ferguson ND, Fan E, Camporota L, Antonelli M, Anzueto A, Beale R, et al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med (2012) 38:1573–82.10.1007/s00134-012-2682-1
    1. Lovas A, Trasy D, Nemeth M, Laszlo I, Molnar Z. Effect of lung recruitment on oxygenation in patients with acute lung injury ventilated in CPAP/pressure support mode. Crit Care (2015) 19:226.10.1186/cc14306
    1. Wiesen J, Ornstein M, Tonelli AR, Menon V, Ashton RW. State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic shock. Heart (2013) 99:1812–7.10.1136/heartjnl-2013-303642
    1. Pinsky MR. Cardiovascular issues in respiratory care. Chest (2005) 128:592S–7S.10.1378/chest.128.5_suppl_2.592S
    1. Rocco PR, Pelosi P. Pulmonary and extrapulmonary acute respiratory distress syndrome: myth or reality? Curr Opin Crit Care (2008) 14:50–5.10.1097/MCC.0b013e3282f2405b
    1. Grasso S, Mascia L, Del Turco M, Malacarne P, Giunta F, Brochard L, et al. Effects of recruiting maneuvers in patients with acute respiratory distress syndrome ventilated with protective ventilatory strategy. Anesthesiology (2002) 96:795–802.10.1097/00000542-200204000-00005
    1. Esan A, Hess DR, Raoof S, George L, Sessler CN. Severe hypoxemic respiratory failure: part 1 – ventilatory strategies. Chest (2010) 137:1203–16.10.1378/chest.09-2415
    1. Schreiter D, Reske A, Stichert B, Seiwerts M, Bohm SH, Kloeppel R, et al. Alveolar recruitment in combination with sufficient positive end-expiratory pressure increases oxygenation and lung aeration in patients with severe chest trauma. Crit Care Med (2004) 32:968–75.10.1097/01.CCM.0000120050.85798.38
    1. Reutershan J, Schmitt A, Dietz K, Unertl K, Fretschner R. Alveolar recruitment during prone position: time matters. Clin Sci (Lond) (2006) 110:655–63.10.1042/CS20050337
    1. Di Marco F, Devaquet J, Lyazidi A, Galia F, da Costa NP, Fumagalli R, et al. Positive end-expiratory pressure-induced functional recruitment in patients with acute respiratory distress syndrome. Crit Care Med (2010) 38:127–32.10.1097/CCM.0b013e3181b4a7e7
    1. Huh JW, Hong SB, Lim CM, Koh Y. Effect of the alveolar recruitment manoeuvre on haemodynamic parameters in patients with acute respiratory distress syndrome: relationship with oxygenation. Respirology (2010) 15:1220–5.10.1111/j.1440-1843.2010.01852.x
    1. Oczenski W, Hörmann C, Keller C, Lorenzl N, Kepka A, Schwarz S. Recruitment maneuvers after a positive end-expiratory pressure trial do not induce sustained effects in early adult respiratory distress syndrome. Anesthesiology (2004) 101:620–5.10.1097/00000542-200409000-00010
    1. Dueck R. Alveolar recruitment versus hyperinflation: a balancing act. Curr Opin Anaesthesiol (2006) 19:650–4.10.1097/ACO.0b013e328011015d
    1. Waydhas C. Intrahospital transport of critically ill patients. Crit Care (1999) 3:R83–9.10.1186/cc362
    1. Patroniti N, Bellani G, Cortinovis B, Foti G, Maggioni E, Manfio A, et al. Role of absolute lung volume to assess alveolar recruitment in acute respiratory distress syndrome patients. Crit Care Med (2010) 38:1300–7.10.1097/CCM.0b013e3181d8cb51
    1. Dellamonica J, Lerolle N, Sargentini C, Beduneau G, Di Marco F, Mercat A, et al. PEEP-induced changes in lung volume in acute respiratory distress syndrome. Two methods to estimate alveolar recruitment. Intensive Care Med (2011) 37:1595–604.10.1007/s00134-011-2333-y
    1. Blanch L, Fernández R, Benito S, Mancebo J, Net A. Effect of PEEP on the arterial minus end-tidal carbon dioxide gradient. Chest (1978) 92:451–4.10.1378/chest.92.3.451
    1. Schumann S, Vimlati L, Kawati R, Guttmann J, Lichtwarck-Aschoff M. Analysis of dynamic intratidal compliance in a lung collapse model. Anesthesiology (2011) 114:1111–7.10.1097/ALN.0b013e31820ad41b
    1. Toth I, Leiner T, Mikor A, Szakmany T, Bogar L, Molnar Z. Hemodynamic and respiratory changes during lung recruitment and descending optimal positive end-expiratory pressure titration in patients with acute respiratory distress syndrome. Crit Care Med (2007) 35:787–93.10.1097/
    1. Villagrá A, Ochagavía A, Vatua S, Murias G, Del Mar Fernández M, Lopez Aguilar J, et al. Recruitment maneuvers during lung protective ventilation in acute respiratory distress syndrome. Am J Respir Crit Care Med (2002) 165:165–70.10.1164/ajrccm.165.2.2104092

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe