Effects of volume shift on the pressure-volume curve of the respiratory system in ALI/ARDS patients.
OBJECTIVE
The pressure-volume (PV) curve in acute lung injury and acute respiratory distress syndrome (ALI/ARDS) patients has been proposed for estimating the underlying pathology, lung recruitment and setting mechanical ventilation. The supersyringe method may lead to artifacts due to thermodynamics and gas exchange. Another possible confounding factor is the volume shift, primarily blood, out of the chest wall when the intrathoracic pressures rise. We set out to quantify the volume shift and investigate its mechanisms.


METHODS
Ten ALI/ARDS patients (5 males/5 females, PaO(2)/FiO(2) 222+/-67) were studied in the Intensive Care Unit, University Hospital. PV curve was performed by a supersyringe (0.100 L, 14 steps Delta-Vgas) while recording the chest wall volume difference (Delta-Vcw) by the optoelectronic plethysmography. Differences in airway (Delta-Paw) and esophageal (Delta-Pes) pressures were measured during the maneuver. Volume shift was defined as Delta-Vcw-Delta-Vgas, corrected for thermodynamic and gas exchange.


RESULTS
Starting compliance (P<0.05), inflation/deflation compliance (P<0.01), hysteresis (P<0.01) and unrecovered volume (P<0.01) were significantly affected by volume shift. The volume shift was directly correlated to the product Delta-Paw*inflation time (R2=0.87, P<0.001), to the ratio of Delta-Pes to Delta-Paw (R2=0.80, P<0.01) and to central venous pressure (R2=0.42, P<0.05) and inversely correlated with the deflation time (R2=0.58, P<0.05). At 20 cmH2O of airway pressure the volume shift between the inflation and deflation limbs of the PV curve amounted to 0.099+/-0.058 L.


CONCLUSIONS
The volume shift, constituted mainly of blood, significantly affects both inspiratory and expiratory PV curve. Caution is needed when interpreting the PV parameters (Minerva Anestesiol 2007;73:1-10).
Chiumello
D
D
Department of Anesthesia and Intensive Care, IRCCS Foundation, Ospedale Maggiore Policlinico, Mangiagalli, Regina Elena, Milan, Italy. chiumello@libero.it
Carlesso
E
E
Aliverti
A
A
Dellacà
R L
RL
Pedotti
A
A
Pelosi
P P
PP
Gattinoni
L
L
D000328:Adult; D000368:Aged; D000399:Air Pressure; D000465:Algorithms; D003627:Data Interpretation, Statistical; D005260:Female; D006801:Humans; D008176:Lung Volume Measurements; D008297:Male; D008875:Middle Aged; D010991:Plethysmography; D012121:Respiration, Artificial; D012128:Respiratory Distress Syndrome / Q000503:physiopathology* / Q000628:therapy*; D015656:Respiratory Mechanics / Q000502:physiology