Role of positive end-expiratory pressure and regional transpulmonary pressure in asymmetrical lung injury

Luca Bastia; Doreen Engelberts; Kohei Osada; Bhushan H. Katira; L. Felipe Damiani; Takeshi Yoshida; Lu Chen; Niall D. Ferguson; Marcelo B.P. Amato; Martin Post; Brian P. Kavanagh; Laurent Brochard

doi:10.1164/RCCM.202005-1556OC

Role of positive end-expiratory pressure and regional transpulmonary pressure in asymmetrical lung injury

Luca Bastia, Doreen Engelberts, Kohei Osada, Bhushan H. Katira, L. Felipe Damiani, Takeshi Yoshida, Lu Chen, Niall D. Ferguson, Marcelo B.P. Amato, Martin Post, Brian P. Kavanagh, Laurent Brochard

Research output: Contribution to journal › Article › peer-review

18 Scopus citations

Abstract

Rationale: Asymmetrical lung injury is a frequent clinical presentation. Regional distribution of VT and positive end-expiratory pressure (PEEP) could result in hyperinflation of the less-injured lung. The validity of esophageal pressure (Pes) is unknown. Objectives: To compare, in asymmetrical lung injury, Pes with directly measured pleural pressures (Ppl) of both sides and investigate how PEEP impacts ventilation distribution and the regional driving transpulmonary pressure (inspiratory - expiratory). Methods: Fourteen mechanically ventilated pigs with lung injury were studied. One lung was blocked while the contralateral one underwent surfactant lavage and injurious ventilation. Airway pressure and Pes were measured, as was Ppl in the dorsal and ventral pleural space adjacent to each lung. Distribution of ventilation was assessed by electrical impedance tomography. PEEP was studied through decremental steps. Measurements and Results: Ventral and dorsal Ppl were similar between the injured and the noninjured lung across all PEEP levels. Dorsal Ppl and Pes were similar. The driving transpulmonary pressure was similar in the two lungs. VT distribution between lungs was different at zero end-expiratory pressure (≈70% of VT going in noninjured lung) owing to different respiratory system compliance (8.3 ml/cm H₂O noninjured lung vs. 3.7 ml/cm H₂O injured lung). PEEP at 10 cm H₂O with transpulmonary pressure around zero homogenized VT distribution opening the lungs. PEEP >16 cm H₂O equalized distribution of VT but with overdistension for both lungs. Conclusions: Despite asymmetrical lung injury, Ppl between injured and noninjured lungs is equalized and esophageal pressure is a reliable estimate of dorsal Ppl. Driving transpulmonary pressure is similar for both lungs. VT distribution results from regional respiratory system compliance. Moderate PEEP homogenizes VT distribution between lungs without generating hyperinflation.

Original language	English
Pages (from-to)	969-976
Number of pages	8
Journal	American journal of respiratory and critical care medicine
Volume	203
Issue number	8
DOIs	https://doi.org/10.1164/RCCM.202005-1556OC
State	Published - 2021

Keywords

Acute lung injury
Esophageal pressure
Mechanical ventilation
Monitoring
Respiratory mechanics

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10.1164/RCCM.202005-1556OC

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Bastia, L., Engelberts, D., Osada, K., Katira, B. H., Damiani, L. F., Yoshida, T., Chen, L., Ferguson, N. D., Amato, M. B. P., Post, M., Kavanagh, B. P., & Brochard, L. (2021). Role of positive end-expiratory pressure and regional transpulmonary pressure in asymmetrical lung injury. American journal of respiratory and critical care medicine, 203(8), 969-976. https://doi.org/10.1164/RCCM.202005-1556OC

@article{1358a7f1cea64678992d59b8d22d7fd1,

title = "Role of positive end-expiratory pressure and regional transpulmonary pressure in asymmetrical lung injury",

abstract = "Rationale: Asymmetrical lung injury is a frequent clinical presentation. Regional distribution of VT and positive end-expiratory pressure (PEEP) could result in hyperinflation of the less-injured lung. The validity of esophageal pressure (Pes) is unknown. Objectives: To compare, in asymmetrical lung injury, Pes with directly measured pleural pressures (Ppl) of both sides and investigate how PEEP impacts ventilation distribution and the regional driving transpulmonary pressure (inspiratory - expiratory). Methods: Fourteen mechanically ventilated pigs with lung injury were studied. One lung was blocked while the contralateral one underwent surfactant lavage and injurious ventilation. Airway pressure and Pes were measured, as was Ppl in the dorsal and ventral pleural space adjacent to each lung. Distribution of ventilation was assessed by electrical impedance tomography. PEEP was studied through decremental steps. Measurements and Results: Ventral and dorsal Ppl were similar between the injured and the noninjured lung across all PEEP levels. Dorsal Ppl and Pes were similar. The driving transpulmonary pressure was similar in the two lungs. VT distribution between lungs was different at zero end-expiratory pressure (≈70% of VT going in noninjured lung) owing to different respiratory system compliance (8.3 ml/cm H2O noninjured lung vs. 3.7 ml/cm H2O injured lung). PEEP at 10 cm H2O with transpulmonary pressure around zero homogenized VT distribution opening the lungs. PEEP >16 cm H2O equalized distribution of VT but with overdistension for both lungs. Conclusions: Despite asymmetrical lung injury, Ppl between injured and noninjured lungs is equalized and esophageal pressure is a reliable estimate of dorsal Ppl. Driving transpulmonary pressure is similar for both lungs. VT distribution results from regional respiratory system compliance. Moderate PEEP homogenizes VT distribution between lungs without generating hyperinflation.",

keywords = "Acute lung injury, Esophageal pressure, Mechanical ventilation, Monitoring, Respiratory mechanics",

author = "Luca Bastia and Doreen Engelberts and Kohei Osada and Katira, {Bhushan H.} and Damiani, {L. Felipe} and Takeshi Yoshida and Lu Chen and Ferguson, {Niall D.} and Amato, {Marcelo B.P.} and Martin Post and Kavanagh, {Brian P.} and Laurent Brochard",

year = "2021",

doi = "10.1164/RCCM.202005-1556OC",

language = "English",

volume = "203",

pages = "969--976",

journal = "American journal of respiratory and critical care medicine",

issn = "1073-449X",

number = "8",

}

Bastia, L, Engelberts, D, Osada, K, Katira, BH, Damiani, LF, Yoshida, T, Chen, L, Ferguson, ND, Amato, MBP, Post, M, Kavanagh, BP & Brochard, L 2021, 'Role of positive end-expiratory pressure and regional transpulmonary pressure in asymmetrical lung injury', American journal of respiratory and critical care medicine, vol. 203, no. 8, pp. 969-976. https://doi.org/10.1164/RCCM.202005-1556OC

TY - JOUR

T1 - Role of positive end-expiratory pressure and regional transpulmonary pressure in asymmetrical lung injury

AU - Bastia, Luca

AU - Engelberts, Doreen

AU - Osada, Kohei

AU - Katira, Bhushan H.

AU - Damiani, L. Felipe

AU - Yoshida, Takeshi

AU - Chen, Lu

AU - Ferguson, Niall D.

AU - Amato, Marcelo B.P.

AU - Post, Martin

AU - Kavanagh, Brian P.

AU - Brochard, Laurent

PY - 2021

Y1 - 2021

N2 - Rationale: Asymmetrical lung injury is a frequent clinical presentation. Regional distribution of VT and positive end-expiratory pressure (PEEP) could result in hyperinflation of the less-injured lung. The validity of esophageal pressure (Pes) is unknown. Objectives: To compare, in asymmetrical lung injury, Pes with directly measured pleural pressures (Ppl) of both sides and investigate how PEEP impacts ventilation distribution and the regional driving transpulmonary pressure (inspiratory - expiratory). Methods: Fourteen mechanically ventilated pigs with lung injury were studied. One lung was blocked while the contralateral one underwent surfactant lavage and injurious ventilation. Airway pressure and Pes were measured, as was Ppl in the dorsal and ventral pleural space adjacent to each lung. Distribution of ventilation was assessed by electrical impedance tomography. PEEP was studied through decremental steps. Measurements and Results: Ventral and dorsal Ppl were similar between the injured and the noninjured lung across all PEEP levels. Dorsal Ppl and Pes were similar. The driving transpulmonary pressure was similar in the two lungs. VT distribution between lungs was different at zero end-expiratory pressure (≈70% of VT going in noninjured lung) owing to different respiratory system compliance (8.3 ml/cm H2O noninjured lung vs. 3.7 ml/cm H2O injured lung). PEEP at 10 cm H2O with transpulmonary pressure around zero homogenized VT distribution opening the lungs. PEEP >16 cm H2O equalized distribution of VT but with overdistension for both lungs. Conclusions: Despite asymmetrical lung injury, Ppl between injured and noninjured lungs is equalized and esophageal pressure is a reliable estimate of dorsal Ppl. Driving transpulmonary pressure is similar for both lungs. VT distribution results from regional respiratory system compliance. Moderate PEEP homogenizes VT distribution between lungs without generating hyperinflation.

AB - Rationale: Asymmetrical lung injury is a frequent clinical presentation. Regional distribution of VT and positive end-expiratory pressure (PEEP) could result in hyperinflation of the less-injured lung. The validity of esophageal pressure (Pes) is unknown. Objectives: To compare, in asymmetrical lung injury, Pes with directly measured pleural pressures (Ppl) of both sides and investigate how PEEP impacts ventilation distribution and the regional driving transpulmonary pressure (inspiratory - expiratory). Methods: Fourteen mechanically ventilated pigs with lung injury were studied. One lung was blocked while the contralateral one underwent surfactant lavage and injurious ventilation. Airway pressure and Pes were measured, as was Ppl in the dorsal and ventral pleural space adjacent to each lung. Distribution of ventilation was assessed by electrical impedance tomography. PEEP was studied through decremental steps. Measurements and Results: Ventral and dorsal Ppl were similar between the injured and the noninjured lung across all PEEP levels. Dorsal Ppl and Pes were similar. The driving transpulmonary pressure was similar in the two lungs. VT distribution between lungs was different at zero end-expiratory pressure (≈70% of VT going in noninjured lung) owing to different respiratory system compliance (8.3 ml/cm H2O noninjured lung vs. 3.7 ml/cm H2O injured lung). PEEP at 10 cm H2O with transpulmonary pressure around zero homogenized VT distribution opening the lungs. PEEP >16 cm H2O equalized distribution of VT but with overdistension for both lungs. Conclusions: Despite asymmetrical lung injury, Ppl between injured and noninjured lungs is equalized and esophageal pressure is a reliable estimate of dorsal Ppl. Driving transpulmonary pressure is similar for both lungs. VT distribution results from regional respiratory system compliance. Moderate PEEP homogenizes VT distribution between lungs without generating hyperinflation.

KW - Acute lung injury

KW - Esophageal pressure

KW - Mechanical ventilation

KW - Monitoring

KW - Respiratory mechanics

UR - http://www.scopus.com/inward/record.url?scp=85104899667&partnerID=8YFLogxK

U2 - 10.1164/RCCM.202005-1556OC

DO - 10.1164/RCCM.202005-1556OC

M3 - Article

C2 - 33091317

AN - SCOPUS:85104899667

SN - 1073-449X

VL - 203

SP - 969

EP - 976

JO - American journal of respiratory and critical care medicine

JF - American journal of respiratory and critical care medicine

IS - 8

ER -

Role of positive end-expiratory pressure and regional transpulmonary pressure in asymmetrical lung injury

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