title: Mechanism by which a sustained inflation can worsen oxygenation in acute lung injury.
abstract: BACKGROUND
  Sustained lung inflations (recruitment maneuvers [RMs]) are occasionally used during mechanical ventilation of patients with acute lung injury to restore aeration to atelectatic alveoli. However, RMs do not improve, and may even worsen, gas exchange in a fraction of these patients. In this study, the authors sought to determine the mechanism by which an RM can impair gas exchange in acute lung injury.
  
  
  METHODS
  The authors selected a model of acute lung injury that was unlikely to exhibit sustained recruitment in response to a lung inflation. In five sheep, lung injury was induced by lavage with 0.2% polysorbate 80 in saline. Positron emission tomography and [13N]nitrogen were used to assess regional lung function in dependent, middle, and nondependent lung regions. Physiologic data and positron emission scans were collected before and 5 min after a sustained inflation (continuous positive airway pressure of 50 cm H2O for 30 s).
  
  
  RESULTS
  All animals showed greater loss of aeration and higher perfusion and shunting blood flow in the dependent region. After the RM, Pao2 decreased in all animals by 35 +/- 22 mmHg (P < 0.05). This decrease in Pao2 was associated with redistribution of pulmonary blood flow from the middle, more aerated region to the dependent, less aerated region (P < 0.05) and with an increase in the fraction of pulmonary blood flow that was shunted in the dependent region (P < 0.05). Neither respiratory compliance nor aeration of the dependent region improved after the RM.
  
  
  CONCLUSIONS
  When a sustained inflation does not restore aeration to atelectatic regions, it can worsen oxygenation by increasing the fraction of pulmonary blood flow that is shunted in nonaerated regions.
authors.affiliation: Department of Anesthesia and Critical Care, CLN 309, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114, USA. gmusch@partners.org
authors.forename: Guido
authors.initials: G
authors.lastname: Musch
authors.forename: R Scott
authors.initials: RS
authors.lastname: Harris
authors.forename: Marcos F
authors.initials: MF
authors.lastname: Vidal Melo
authors.forename: Kevin R
authors.initials: KR
authors.lastname: O'Neill
authors.forename: J Dominick H
authors.initials: JD
authors.lastname: Layfield
authors.forename: Tilo
authors.initials: T
authors.lastname: Winkler
authors.forename: Jose G
authors.initials: JG
authors.lastname: Venegas
mesh_terms: D000818:Animals; D001794:Blood Pressure; D004195:Disease Models, Animal; D011659:Pulmonary Gas Exchange; D012121:Respiration, Artificial / Q000009:adverse effects*; D012128:Respiratory Distress Syndrome / Q000503:physiopathology / Q000628:therapy*; D012756:Sheep; D014055:Tomography, Emission-Computed