title: Airway pressure release ventilation prevents ventilator-induced lung injury in normal lungs.
abstract: OBJECTIVE
  Up to 25% of patients with normal lungs develop acute lung injury (ALI) secondary to mechanical ventilation, with 60% to 80% progressing to acute respiratory distress syndrome (ARDS). Once established, ARDS is treated with mechanical ventilation that can paradoxically elevate mortality. A ventilation strategy that reduces the incidence of ARDS could change the clinical paradigm from treatment to prevention.
  
  
  OBJECTIVE
  To demonstrate that (1) mechanical ventilation with tidal volume (VT) and positive end-expiratory pressure (PEEP) settings used routinely on surgery patients causes ALI/ARDS in normal rats and (2) preemptive application of airway pressure release ventilation (APRV) blocks drivers of lung injury (ie, surfactant deactivation and alveolar edema) and prevents ARDS.
  
  
  METHODS
  Rats were anesthetized and tracheostomy was performed at State University of New York Upstate Medical University. Arterial and venous lines, a peritoneal catheter, and a rectal temperature probe were inserted. Animals were randomized into 3 groups and followed up for 6 hours: spontaneous breathing ventilation (SBV, n = 5), continuous mandatory ventilation (CMV, n = 6), and APRV (n = 5). Rats in the CMV group were ventilated with Vt of 10 cc/kg and PEEP of 0.5 cm H2O. Airway pressure release ventilation was set with a P(High) of 15 to 20 cm H2O; P(Low) was set at 0 cm H2O. Time at P(High) (T(High)) was 1.3 to 1.5 seconds and a T(Low) was set to terminate at 75% of the peak expiratory flow rate (0.11-0.14 seconds), creating a minimum 90% cycle time spent at P(High). Bronchoalveolar lavage fluid and lungs were harvested for histopathologic analysis at necropsy.
  
  
  RESULTS
  Acute lung injury/ARDS developed in the CMV group (mean [SE] PaO2/FiO2 ratio, 242.96 [24.82]) and was prevented with preemptive APRV (mean [SE] PaO2/FIO2 ratio, 478.00 [41.38]; P < .05). Airway pressure release ventilation also significantly reduced histopathologic changes and bronchoalveolar lavage fluid total protein (endothelial permeability) and preserved surfactant proteins A and B concentrations as compared with the CMV group.
  
  
  CONCLUSIONS
  Continuous mandatory ventilation in normal rats for 6 hours with Vt and PEEP settings similar to those of surgery patients caused ALI. Preemptive application of APRV blocked early drivers of lung injury, preventing ARDS. Our data suggest that APRV applied early could reduce the incidence of ARDS in patients at risk.
authors.affiliation: State University of New York Upstate Medical University, Syracuse, New York.
authors.forename: Bryanna
authors.initials: B
authors.lastname: Emr
authors.forename: Louis A
authors.initials: LA
authors.lastname: Gatto
authors.forename: Shreyas
authors.initials: S
authors.lastname: Roy
authors.forename: Joshua
authors.initials: J
authors.lastname: Satalin
authors.forename: Auyon
authors.initials: A
authors.lastname: Ghosh
authors.forename: Kathy
authors.initials: K
authors.lastname: Snyder
authors.forename: Penny
authors.initials: P
authors.lastname: Andrews
authors.forename: Nader
authors.initials: N
authors.lastname: Habashi
authors.forename: William
authors.initials: W
authors.lastname: Marx
authors.forename: Lin
authors.initials: L
authors.lastname: Ge
authors.forename: Guirong
authors.initials: G
authors.lastname: Wang
authors.forename: David A
authors.initials: DA
authors.lastname: Dean
authors.forename: Yoram
authors.initials: Y
authors.lastname: Vodovotz
authors.forename: Gary
authors.initials: G
authors.lastname: Nieman
mesh_terms: D000818:Animals; D045422:Continuous Positive Airway Pressure / Q000009:adverse effects / Q000379:methods*; D004195:Disease Models, Animal; D008297:Male; D010366:Peak Expiratory Flow Rate / Q000502:physiology; D051381:Rats; D017207:Rats, Sprague-Dawley; D012128:Respiratory Distress Syndrome / Q000209:etiology / Q000473:pathology / Q000517:prevention & control*; D013990:Tidal Volume / Q000502:physiology; D013997:Time Factors; D055397:Ventilator-Induced Lung Injury / Q000209:etiology / Q000473:pathology / Q000517:prevention & control*