Set positive end-expiratory pressure during protective ventilation affects lung injury.
BACKGROUND
The most appropriate method of determining positive end-expiratory pressure (PEEP) level during a lung protective ventilatory strategy has not been established.


METHODS
In a lavage-injured sheep acute respiratory distress syndrome model, the authors compared the effects of three approaches to determining PEEP level after a recruitment maneuver: (1) 2 cm H(2)O above the lower inflection point on the inflation pressure-volume curve, (2) at the point of maximum curvature on the deflation pressure-volume curve, and (3) at the PEEP level that maintained target arterial oxygen partial pressure at a fraction of inspired oxygen of 0.5.


RESULTS
Positive end-expiratory pressure set 2 cm H(2)O above the lower inflection point resulted in the least injury over the course of the study. PEEP based on adequate arterial oxygen partial pressure/fraction of inspired oxygen ratios had to be increased over time and resulted in higher mRNA levels for interleukin-8 and interleukin-1beta and greater tissue inflammation when compared with the other approaches. PEEP at the point of maximum curvature could not maintain eucapneia even at an increased ventilatory rate.


CONCLUSIONS
Although generating higher plateau pressures, PEEP levels based on pressure-volume curve analysis were more effective in maintaining gas exchange and minimizing injury than PEEP based on adequate oxygenation. PEEP at 2 cm H(2)O above the lower inflection point was most effective.
Takeuchi
Muneyuki
M
Department of Anesthesia/Respiratory Care, Massachusetts General Hospital, The Center for Blood Research, Boston 02114, USA.
Goddon
Sven
S
Dolhnikoff
Marisa
M
Shimaoka
Motomu
M
Hess
Dean
D
Amato
Marcelo B P
MB
Kacmarek
Robert M
RM
D000399:Air Pressure; D000818:Animals; D006439:Hemodynamics / Q000502:physiology; D006651:Histocytochemistry; D008168:Lung / Q000473:pathology / Q000503:physiopathology; D055370:Lung Injury; D008176:Lung Volume Measurements; D010100:Oxygen / Q000097:blood; D011175:Positive-Pressure Respiration; D012121:Respiration, Artificial; D012128:Respiratory Distress Syndrome / Q000503:physiopathology; D015656:Respiratory Mechanics / Q000502:physiology; D020133:Reverse Transcriptase Polymerase Chain Reaction; D012756:Sheep; D007507:Therapeutic Irrigation; D014655:Vascular Resistance / Q000502:physiology
D010100:Oxygen