title: Anatomical and functional intrapulmonary shunt in acute respiratory distress syndrome.
abstract: OBJECTIVE
  The lung-protective strategy employs positive end-expiratory pressure to keep open otherwise collapsed lung regions (anatomical recruitment). Improvement in venous admixture with positive end-expiratory pressure indicates functional recruitment to better gas exchange, which is not necessarily related to anatomical recruitment, because of possible global/regional perfusion modifications. Therefore, we aimed to assess the value of venous admixture (functional shunt) in estimating the fraction of nonaerated lung tissue (anatomical shunt compartment) and to describe their relationship.
  
  
  METHODS
  Retrospective analysis of a previously published study.
  
  
  METHODS
  Intensive care units of four university hospitals.
  
  
  METHODS
  Fifty-nine patients with acute lung injury/acute respiratory distress syndrome.
  
  
  METHODS
  Positive end-expiratory pressure trial at 5 and 15 cm H2O positive end-expiratory pressures.
  
  
  RESULTS
  Anatomical shunt compartment (whole-lung computed tomography scan) and functional shunt (blood gas analysis) were assessed at 5 and 15 cm H2O positive end-expiratory pressures. Apparent perfusion ratio (perfusion per gram of nonaerated tissue/perfusion per gram of total lung tissue) was defined as the ratio of functional shunt to anatomical shunt compartment. Functional shunt was poorly correlated to the anatomical shunt compartment (r2 = .174). The apparent perfusion ratio at 5 cm H2O positive end-expiratory pressure was widely distributed and averaged 1.25 +/- 0.80. The apparent perfusion ratios at 5 and 15 cm H2O positive end-expiratory pressures were highly correlated, with a slope close to identity (y = 1.10.x -0.03, r2 = .759), suggesting unchanged blood flow distribution toward the nonaerated lung tissue, when increasing positive end-expiratory pressure.
  
  
  CONCLUSIONS
  Functional shunt poorly estimates the anatomical shunt compartment, due to the large variability in apparent perfusion ratio. Changes in anatomical shunt compartment with increasing positive end-expiratory pressure, in each individual patient, may be estimated from changes in functional shunt, only if the anatomical-functional shunt relationship at 5 cm H2O positive end-expiratory pressure is known.
authors: Istituto di Anestesiologia e Rianimazione, Università degli Studi di Milano, Milan, Italy.
authors: Massimo
authors: M
authors: Cressoni
authors: Pietro
authors: P
authors: Caironi
authors: Federico
authors: F
authors: Polli
authors: Eleonora
authors: E
authors: Carlesso
authors: Davide
authors: D
authors: Chiumello
authors: Paolo
authors: P
authors: Cadringher
authors: Micheal
authors: M
authors: Quintel
authors: Vito Marco
authors: VM
authors: Ranieri
authors: Guillermo
authors: G
authors: Bugedo
authors: Luciano
authors: L
authors: Gattinoni
mesh_terms: D006801:Humans; D011175:Positive-Pressure Respiration; D011652:Pulmonary Circulation; D012128:Respiratory Distress Syndrome / Q000503:physiopathology* / Q000628:therapy*; D012189:Retrospective Studies