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Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP
BACKGROUND: Chest wall loading has been shown to paradoxically improve respiratory system compliance (C(RS)) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The most likely, albeit unconfirmed, mechanism is relief of end-tidal overdistension in ‘baby lungs’ of low-cap...
Autores principales: | , , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
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BioMed Central
2022
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9255488/ https://www.ncbi.nlm.nih.gov/pubmed/35791021 http://dx.doi.org/10.1186/s13054-022-04073-2 |
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author | Selickman, John Tawfik, Pierre Crooke, Philip S. Dries, David J. Shelver, Jonathan Gattinoni, Luciano Marini, John J. |
author_facet | Selickman, John Tawfik, Pierre Crooke, Philip S. Dries, David J. Shelver, Jonathan Gattinoni, Luciano Marini, John J. |
author_sort | Selickman, John |
collection | PubMed |
description | BACKGROUND: Chest wall loading has been shown to paradoxically improve respiratory system compliance (C(RS)) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The most likely, albeit unconfirmed, mechanism is relief of end-tidal overdistension in ‘baby lungs’ of low-capacity. The purpose of this study was to define how small changes of tidal volume (V(T)) and positive end-expiratory pressure (PEEP) affect C(RS) (and its associated airway pressures) in patients with ARDS who demonstrate a paradoxical response to chest wall loading. We hypothesized that small reductions of V(T) or PEEP would alleviate overdistension and favorably affect C(RS) and conversely, that small increases of V(T) or PEEP would worsen C(RS). METHODS: Prospective, multi-center physiologic study of seventeen patients with moderate to severe ARDS who demonstrated paradoxical responses to chest wall loading. All patients received mechanical ventilation in volume control mode and were passively ventilated. Airway pressures were measured before and after decreasing/increasing V(T) by 1 ml/kg predicted body weight and decreasing/increasing PEEP by 2.5 cmH(2)O. RESULTS: Decreasing either V(T) or PEEP improved C(RS) in all patients. Driving pressure (DP) decreased by a mean of 4.9 cmH(2)O (supine) and by 4.3 cmH(2)O (prone) after decreasing V(T), and by a mean of 2.9 cmH(2)O (supine) and 2.2 cmH(2)O (prone) after decreasing PEEP. C(RS) increased by a mean of 3.1 ml/cmH(2)O (supine) and by 2.5 ml/cmH(2)O (prone) after decreasing V(T.) C(RS) increased by a mean of 5.2 ml/cmH(2)O (supine) and 3.6 ml/cmH(2)O (prone) after decreasing PEEP (P < 0.01 for all). Small increments of either V(T) or PEEP worsened C(RS) in the majority of patients. CONCLUSION: Patients with a paradoxical response to chest wall loading demonstrate uniform improvement in both DP and C(RS) following a reduction in either V(T) or PEEP, findings in keeping with prior evidence suggesting its presence is a sign of end-tidal overdistension. The presence of ‘paradox’ should prompt re-evaluation of modifiable determinants of end-tidal overdistension, including V(T), PEEP, and body position. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13054-022-04073-2. |
format | Online Article Text |
id | pubmed-9255488 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2022 |
publisher | BioMed Central |
record_format | MEDLINE/PubMed |
spelling | pubmed-92554882022-07-06 Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP Selickman, John Tawfik, Pierre Crooke, Philip S. Dries, David J. Shelver, Jonathan Gattinoni, Luciano Marini, John J. Crit Care Research BACKGROUND: Chest wall loading has been shown to paradoxically improve respiratory system compliance (C(RS)) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The most likely, albeit unconfirmed, mechanism is relief of end-tidal overdistension in ‘baby lungs’ of low-capacity. The purpose of this study was to define how small changes of tidal volume (V(T)) and positive end-expiratory pressure (PEEP) affect C(RS) (and its associated airway pressures) in patients with ARDS who demonstrate a paradoxical response to chest wall loading. We hypothesized that small reductions of V(T) or PEEP would alleviate overdistension and favorably affect C(RS) and conversely, that small increases of V(T) or PEEP would worsen C(RS). METHODS: Prospective, multi-center physiologic study of seventeen patients with moderate to severe ARDS who demonstrated paradoxical responses to chest wall loading. All patients received mechanical ventilation in volume control mode and were passively ventilated. Airway pressures were measured before and after decreasing/increasing V(T) by 1 ml/kg predicted body weight and decreasing/increasing PEEP by 2.5 cmH(2)O. RESULTS: Decreasing either V(T) or PEEP improved C(RS) in all patients. Driving pressure (DP) decreased by a mean of 4.9 cmH(2)O (supine) and by 4.3 cmH(2)O (prone) after decreasing V(T), and by a mean of 2.9 cmH(2)O (supine) and 2.2 cmH(2)O (prone) after decreasing PEEP. C(RS) increased by a mean of 3.1 ml/cmH(2)O (supine) and by 2.5 ml/cmH(2)O (prone) after decreasing V(T.) C(RS) increased by a mean of 5.2 ml/cmH(2)O (supine) and 3.6 ml/cmH(2)O (prone) after decreasing PEEP (P < 0.01 for all). Small increments of either V(T) or PEEP worsened C(RS) in the majority of patients. CONCLUSION: Patients with a paradoxical response to chest wall loading demonstrate uniform improvement in both DP and C(RS) following a reduction in either V(T) or PEEP, findings in keeping with prior evidence suggesting its presence is a sign of end-tidal overdistension. The presence of ‘paradox’ should prompt re-evaluation of modifiable determinants of end-tidal overdistension, including V(T), PEEP, and body position. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13054-022-04073-2. BioMed Central 2022-07-05 /pmc/articles/PMC9255488/ /pubmed/35791021 http://dx.doi.org/10.1186/s13054-022-04073-2 Text en © The Author(s) 2022 https://creativecommons.org/licenses/by/4.0/Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ (https://creativecommons.org/licenses/by/4.0/) . The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/ (https://creativecommons.org/publicdomain/zero/1.0/) ) applies to the data made available in this article, unless otherwise stated in a credit line to the data. |
spellingShingle | Research Selickman, John Tawfik, Pierre Crooke, Philip S. Dries, David J. Shelver, Jonathan Gattinoni, Luciano Marini, John J. Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP |
title | Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP |
title_full | Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP |
title_fullStr | Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP |
title_full_unstemmed | Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP |
title_short | Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP |
title_sort | paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or peep |
topic | Research |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9255488/ https://www.ncbi.nlm.nih.gov/pubmed/35791021 http://dx.doi.org/10.1186/s13054-022-04073-2 |
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