title: The open lung during small tidal volume ventilation: concepts of recruitment and "optimal" positive end-expiratory pressure.
abstract: OBJECTIVE
  To test the hypotheses that during small tidal volume ventilation (5 mL/kg) deliberate volume recruitment maneuvers allow expansion of atelectatic lung units and that a high positive end-expiratory pressure (PEEP) above the lower inflection point of the pressure/volume (PV) curve is not necessarily required to maintain recruited lung volume in acute lung injury.
  
  
  METHODS
  Prospective, randomized, controlled animal study.
  
  
  METHODS
  An animal laboratory in a university setting.
  
  
  METHODS
  Adult New-Zealand rabbits.
  
  
  METHODS
  We studied a) the relationship of dynamic loops during intermittent positive pressure ventilation to the quasi-static PV curve, and b) the effect of lung recruitment on oxygenation, end-expiratory lung volume (EELV), and dynamic compliance in two groups (n = 4 per group) of lung-injured animals (lung lavage model): 1) the sustained inflation group, which received ventilation after a recruitment maneuver (sustained inflation); and 2) the control group, which received ventilation without any lung recruitment.
  
  
  RESULTS
  In the presence of PV hysteresis, a single sustained inflation to 30 cm H2O boosted the ventilatory cycle onto the deflation limb of the PV curve. This resulted in a significant increase in EELV, oxygenation, and dynamic compliance despite equal PEEP levels used before and after the recruitment maneuver. Furthermore, after a single sustained inflation, oxygenation remained high over 4 hrs of ventilation when a PEEP above the critical closing pressure of the lungs, defined as "optimal" PEEP, was used and was significantly higher compared with that in the control group ventilated at equal PEEP without preceding lung recruitment.
  
  
  CONCLUSIONS
  The observation that ventilation occurs on the deflation limb of the tidal cycle-specific PV curve allows placement of the ventilatory cycle, by means of a recruitment maneuver, onto the deflation limb of the PV envelope of the optimally recruited lung. This strategy ensures sufficient lung volume recruitment to maintain the lungs during the tidal cycle while using relatively low airway pressures.
authors.affiliation: Department of Critical Care, The Hospital for Sick Children, University of Toronto, Ontario, Canada. peter.rimensberger@hcuge.ch
authors.forename: P C
authors.initials: PC
authors.lastname: Rimensberger
authors.forename: P N
authors.initials: PN
authors.lastname: Cox
authors.forename: H
authors.initials: H
authors.lastname: Frndova
authors.forename: A C
authors.initials: AC
authors.lastname: Bryan
mesh_terms: D000704:Analysis of Variance; D000818:Animals; D007327:Insufflation; D007385:Intermittent Positive-Pressure Ventilation / Q000379:methods*; D008170:Lung Compliance; D011175:Positive-Pressure Respiration; D011446:Prospective Studies; D011817:Rabbits; D011897:Random Allocation; D012128:Respiratory Distress Syndrome / Q000628:therapy*; D015656:Respiratory Mechanics; D018709:Statistics, Nonparametric; D014109:Total Lung Capacity