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Alveolar instability (atelectrauma) is not identified by arterial oxygenation predisposing the development of an occult ventilator-induced lung injury
BACKGROUND: Improperly set mechanical ventilation (MV) with normal lungs can advance lung injury and increase the incidence of acute respiratory distress syndrome (ARDS). A key mechanism of ventilator-induced lung injury (VILI) is an alteration in alveolar mechanics including alveolar instability or...
Autores principales: | , , , , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
Springer International Publishing
2015
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4480795/ https://www.ncbi.nlm.nih.gov/pubmed/26215818 http://dx.doi.org/10.1186/s40635-015-0054-1 |
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author | Andrews, Penny L Sadowitz, Benjamin Kollisch-Singule, Michaela Satalin, Joshua Roy, Shreyas Snyder, Kathy Gatto, Louis A Nieman, Gary F Habashi, Nader M |
author_facet | Andrews, Penny L Sadowitz, Benjamin Kollisch-Singule, Michaela Satalin, Joshua Roy, Shreyas Snyder, Kathy Gatto, Louis A Nieman, Gary F Habashi, Nader M |
author_sort | Andrews, Penny L |
collection | PubMed |
description | BACKGROUND: Improperly set mechanical ventilation (MV) with normal lungs can advance lung injury and increase the incidence of acute respiratory distress syndrome (ARDS). A key mechanism of ventilator-induced lung injury (VILI) is an alteration in alveolar mechanics including alveolar instability or recruitment/derecruitment (R/D). We hypothesize that R/D cannot be identified by PaO(2) (masking occult VILI), and if protective ventilation is not applied, ARDS incidence will increase. METHODS: Sprague-Dawley rats (n = 8) were anesthetized, surgically instrumented, and placed on MV. A thoracotomy was performed and an in vivo microscope attached to the pleural surface of the lung with baseline dynamic changes in alveolar size during MV recorded. Alveolar instability was induced by intra-tracheal instillation of Tween and alveolar R/D identified as a marked change in alveolar size from inspiration to expiration with increases in positive end-expiratory pressure (PEEP) levels. RESULTS: Despite maintaining a clinically acceptable PaO(2) (55–80 mmHg), the alveoli remained unstable with significant R/D at low PEEP levels. Although PaO(2) consistently increased with an increase in PEEP, R/D did not plateau until PEEP was >9 cmH(2)O. CONCLUSIONS: PaO(2) remained clinically acceptable while alveolar instability persisted at all levels of PEEP (especially PEEP <9 cmH(2)O). Therefore, PaO(2) levels cannot be used reliably to guide protective MV strategies or infer that VILI is not occurring. Using PaO(2) to set a PEEP level necessary to stabilize the alveoli could underestimate the potential for VILI. These findings highlight the need for more accurate marker(s) of alveolar stability to guide protective MV necessary to prevent VILI. |
format | Online Article Text |
id | pubmed-4480795 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2015 |
publisher | Springer International Publishing |
record_format | MEDLINE/PubMed |
spelling | pubmed-44807952015-07-22 Alveolar instability (atelectrauma) is not identified by arterial oxygenation predisposing the development of an occult ventilator-induced lung injury Andrews, Penny L Sadowitz, Benjamin Kollisch-Singule, Michaela Satalin, Joshua Roy, Shreyas Snyder, Kathy Gatto, Louis A Nieman, Gary F Habashi, Nader M Intensive Care Med Exp Research BACKGROUND: Improperly set mechanical ventilation (MV) with normal lungs can advance lung injury and increase the incidence of acute respiratory distress syndrome (ARDS). A key mechanism of ventilator-induced lung injury (VILI) is an alteration in alveolar mechanics including alveolar instability or recruitment/derecruitment (R/D). We hypothesize that R/D cannot be identified by PaO(2) (masking occult VILI), and if protective ventilation is not applied, ARDS incidence will increase. METHODS: Sprague-Dawley rats (n = 8) were anesthetized, surgically instrumented, and placed on MV. A thoracotomy was performed and an in vivo microscope attached to the pleural surface of the lung with baseline dynamic changes in alveolar size during MV recorded. Alveolar instability was induced by intra-tracheal instillation of Tween and alveolar R/D identified as a marked change in alveolar size from inspiration to expiration with increases in positive end-expiratory pressure (PEEP) levels. RESULTS: Despite maintaining a clinically acceptable PaO(2) (55–80 mmHg), the alveoli remained unstable with significant R/D at low PEEP levels. Although PaO(2) consistently increased with an increase in PEEP, R/D did not plateau until PEEP was >9 cmH(2)O. CONCLUSIONS: PaO(2) remained clinically acceptable while alveolar instability persisted at all levels of PEEP (especially PEEP <9 cmH(2)O). Therefore, PaO(2) levels cannot be used reliably to guide protective MV strategies or infer that VILI is not occurring. Using PaO(2) to set a PEEP level necessary to stabilize the alveoli could underestimate the potential for VILI. These findings highlight the need for more accurate marker(s) of alveolar stability to guide protective MV necessary to prevent VILI. Springer International Publishing 2015-06-09 /pmc/articles/PMC4480795/ /pubmed/26215818 http://dx.doi.org/10.1186/s40635-015-0054-1 Text en © Andrews et al. 2015 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. |
spellingShingle | Research Andrews, Penny L Sadowitz, Benjamin Kollisch-Singule, Michaela Satalin, Joshua Roy, Shreyas Snyder, Kathy Gatto, Louis A Nieman, Gary F Habashi, Nader M Alveolar instability (atelectrauma) is not identified by arterial oxygenation predisposing the development of an occult ventilator-induced lung injury |
title | Alveolar instability (atelectrauma) is not identified by arterial oxygenation predisposing the development of an occult ventilator-induced lung injury |
title_full | Alveolar instability (atelectrauma) is not identified by arterial oxygenation predisposing the development of an occult ventilator-induced lung injury |
title_fullStr | Alveolar instability (atelectrauma) is not identified by arterial oxygenation predisposing the development of an occult ventilator-induced lung injury |
title_full_unstemmed | Alveolar instability (atelectrauma) is not identified by arterial oxygenation predisposing the development of an occult ventilator-induced lung injury |
title_short | Alveolar instability (atelectrauma) is not identified by arterial oxygenation predisposing the development of an occult ventilator-induced lung injury |
title_sort | alveolar instability (atelectrauma) is not identified by arterial oxygenation predisposing the development of an occult ventilator-induced lung injury |
topic | Research |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4480795/ https://www.ncbi.nlm.nih.gov/pubmed/26215818 http://dx.doi.org/10.1186/s40635-015-0054-1 |
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