title: Transpulmonary and pleural pressure in a respiratory system model with an elastic recoiling lung and an expanding chest wall.
abstract: BACKGROUND
  We have shown in acute lung injury patients that lung elastance can be determined by a positive end-expiratory pressure (PEEP) step procedure and proposed that this is explained by the spring-out force of the rib cage off-loading the chest wall from the lung at end-expiration. The aim of this study was to investigate the effect of the expanding chest wall on pleural pressure during PEEP inflation by building a model with an elastic recoiling lung and an expanding chest wall complex.
  
  
  METHODS
  Test lungs with a compliance of 19, 38, or 57 ml/cmH2O were placed in a box connected to a plastic container, 3/4 filled with water, connected to a water sack of 10 l, representing the abdomen. The space above the water surface and in the lung box constituted the pleural space. The contra-directional forces of the recoiling lung and the expanding chest wall were obtained by evacuating the pleural space to a negative pressure of 5 cmH2O. Chest wall elastance was increased by strapping the plastic container. Pressure was measured in the airway and pleura. Changes in end-expiratory lung volume (ΔEELV), during PEEP steps of 4, 8, and 12 cmH2O, were determined in the isolated lung, where airway equals transpulmonary pressure and in the complete model as the cumulative inspiratory-expiratory tidal volume difference. Transpulmonary pressure was calculated as airway minus pleural pressure.
  
  
  RESULTS
  Lung pressure/volume curves of an isolated lung coincided with lung P/V curves in the complete model irrespective of chest wall stiffness. ΔEELV was equal to the size of the PEEP step divided by lung elastance (EL), ΔEELV = ΔPEEP/EL. The end-expiratory "pleural" pressure did not increase after PEEP inflation, and consequently, transpulmonary pressure increased as much as PEEP was increased.
  
  
  CONCLUSIONS
  The rib cage spring-out force causes off-loading of the chest wall from the lung and maintains a negative end-expiratory "pleural" pressure after PEEP inflation. The behavior of the respiratory system model confirms that lung elastance can be determined by a simple PEEP step without using esophageal pressure measurements.
authors.affiliation: Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Blå Stråket 5, 413 45, Gothenburg, Sweden.
authors.forename: Per
authors.initials: P
authors.lastname: Persson
authors.affiliation: Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Blå Stråket 5, 413 45, Gothenburg, Sweden.
authors.forename: Stefan
authors.initials: S
authors.lastname: Lundin
authors.affiliation: Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Blå Stråket 5, 413 45, Gothenburg, Sweden. ola.stenqvist@aniv.gu.se.
authors.forename: Ola
authors.initials: O
authors.lastname: Stenqvist
keywords: Expanding chest wall; Lung elastance; PEEP step maneuver; Transpulmonary pressure