title: There is no cephalocaudal gradient of computed tomography densities or lung behavior in supine patients with acute respiratory distress syndrome.
abstract: There is debate whether pressure transmission within the lungs and alveolar collapse follow a hydrostatic pattern or the compression exerted by the weight of the heart and the diaphragm causes collapse localized in the areas adjacent to these structures. The second hypothesis proposes the existence of a cephalocaudal gradient in alveolar collapse. We aimed to define whether or not lung density and collapse follow a 'liquid-like' pattern with homogeneous isogravitational layers along the cephalocaudal axis in acute respiratory distress syndrome lungs.
  
  
  
  Acute respiratory distress syndrome patients were submitted to full lung computed tomography scans at positive end-expiratory pressure (PEEP) zero (before) and 25 cmH2 O after a maximum-recruitment maneuver. PEEP was then decreased by 2 cmH2 O every 4 min, and a semi-complete scan performed at the end of each PEEP step.
  
  
  
  Lung densities were homogeneous within each lung layer. Lung density increased along the ventrodorsal axis toward the dorsal region (β = 0.49, P < 0.001), while there was no increase, but rather a slight decrease, toward the diaphragm along the cephalocaudal axis and toward the heart. Higher PEEP attenuated density gradients. At PEEP 18 cmH2 O, dependent lung regions started to collapse massively, while best compliance was only reached at a lower PEEP.
  
  
  
  We could not detect cephalocaudal gradients in lung densities or in alveolar collapse. Likely, external pressures applied on the lung by the chest wall, organs, and effusions are transmitted throughout the lung in a hydrostatic pattern with homogeneous consequences at each isogravitational layer. A single cross-sectional image of the lung could fully represent the heterogeneous mechanical properties of dependent and non-dependent lung regions.
authors.affiliation: Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.
authors.forename: S A
authors.initials: SA
authors.lastname: El-Dash
authors.affiliation: Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.|Section of Anaesthesiology & Critical Care, Department of Surgical Sciences, Hedenstierna Laboratory, Uppsala University, Uppsala, Sweden.
authors.forename: J B
authors.initials: JB
authors.lastname: Borges
authors.affiliation: Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.|Research and Education Institute of Hospital Sírio Libanês, São Paulo, Brazil.
authors.forename: E L V
authors.initials: EL
authors.lastname: Costa
authors.affiliation: Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.
authors.forename: M R
authors.initials: MR
authors.lastname: Tucci
authors.affiliation: Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.
authors.forename: O T
authors.initials: OT
authors.lastname: Ranzani
authors.affiliation: Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.
authors.forename: M P
authors.initials: MP
authors.lastname: Caramez
authors.affiliation: Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.
authors.forename: C R R
authors.initials: CR
authors.lastname: Carvalho
authors.affiliation: Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.
authors.forename: M B P
authors.initials: MB
authors.lastname: Amato
mesh_terms: D000293:Adolescent; D000328:Adult; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008168:Lung / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D011175:Positive-Pressure Respiration; D011650:Pulmonary Alveoli / Q000000981:diagnostic imaging / Q000503:physiopathology; D012128:Respiratory Distress Syndrome / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D016683:Supine Position / Q000502:physiology; D014057:Tomography, X-Ray Computed / Q000379:methods*; D055815:Young Adult