title: Matching positive end-expiratory pressure to intra-abdominal pressure improves oxygenation in a porcine sick lung model of intra-abdominal hypertension.
abstract: BACKGROUND
  Intra-abdominal hypertension (IAH) causes atelectasis, reduces lung volumes and increases respiratory system elastance. Positive end-expiratory pressure (PEEP) in the setting of IAH and healthy lungs improves lung volumes but not oxygenation. However, critically ill patients with IAH often suffer from acute lung injury (ALI). This study, therefore, examined the respiratory and cardiac effects of positive end-expiratory pressure in an animal model of IAH, with sick lungs.
  
  
  METHODS
  Nine pigs were anesthetized and ventilated (48 +/- 6 kg). Lung injury was induced with oleic acid. Three levels of intra-abdominal pressure (baseline, 18, and 22 mmHg) were randomly generated. At each level of intra-abdominal pressure, three levels of PEEP were randomly applied: baseline (5 cmH2O), moderate (0.5 × intra-abdominal pressure), and high (1.0 × intra-abdominal pressure). We measured end-expiratory lung volumes, arterial oxygen levels, respiratory mechanics, and cardiac output 10 minutes after each new IAP and PEEP setting.
  
  
  RESULTS
  At baseline PEEP, IAH (22 mmHg) decreased oxygen levels (-55%, P <0.001) and end-expiratory lung volumes (-45%, P = 0.007). At IAP of 22 mmHg, moderate and high PEEP increased oxygen levels (+60%, P = 0.04 and +162%, P <0.001) and end-expiratory lung volume (+44%, P = 0.02 and +279%, P <0.001) and high PEEP reduced cardiac output (-30%, P = 0.04). Shunt and dead-space fraction inversely correlated with oxygen levels and end-expiratory lung volumes. In the presence of IAH, lung, chest wall and respiratory system elastance increased. Subsequently, PEEP decreased respiratory system elastance by decreasing chest wall elastance.
  
  
  CONCLUSIONS
  In a porcine sick lung model of IAH, PEEP matched to intra-abdominal pressure led to increased lung volumes and oxygenation and decreased chest wall elastance shunt and dead-space fraction. High PEEP decreased cardiac output. The study shows that lung injury influences the effects of IAH and PEEP on oxygenation and respiratory mechanics. Our findings support the application of PEEP in the setting of acute lung injury and IAH.
authors.forename: Adrian
authors.initials: A
authors.lastname: Regli
authors.forename: Rohan
authors.initials: R
authors.lastname: Mahendran
authors.forename: Edward T
authors.initials: ET
authors.lastname: Fysh
authors.forename: Brigit
authors.initials: B
authors.lastname: Roberts
authors.forename: Bill
authors.initials: B
authors.lastname: Noffsinger
authors.forename: Bart L
authors.initials: BL
authors.lastname: De Keulenaer
authors.forename: Bhajan
authors.initials: B
authors.lastname: Singh
authors.forename: Peter V
authors.initials: PV
authors.lastname: van Heerden
mesh_terms: D034841:Abdominal Cavity / Q000503:physiopathology; D055371:Acute Lung Injury / Q000209:etiology / Q000628:therapy*; D000818:Animals; D002302:Cardiac Output / Q000502:physiology; D004195:Disease Models, Animal; D059325:Intra-Abdominal Hypertension / Q000150:complications / Q000628:therapy*; D008170:Lung Compliance / Q000502:physiology; D008176:Lung Volume Measurements; D010100:Oxygen / Q000378:metabolism*; D011175:Positive-Pressure Respiration / Q000379:methods*; D011312:Pressure; D013552:Swine
chemical_list: D010100:Oxygen