Am. J. Respir. Crit. Care Med., Volume 156, Number 3, September 1997, 846-854

Impact of Positive End-expiratory Pressure on Chest Wall and Lung Pressure-Volume Curve in Acute Respiratory Failure

MARIO MERGONI, ALESSANDRA MARTELLI, ANNALISA VOLPI, STEFANIA PRIMAVERA, PAOLO ZUCCOLI, and ANDREA ROSSI

1° Servizio di Anestesia e Rianimazione, Azienda Ospedaliera di Parma, Parma; and Servizio di Fisiopatologia Respiratoria, Azienda Ospedaliera di Verona, Verona, Italy

To investigate whether chest-wall mechanics could affect the total respiratory system pressure-volume (P-V) curve in patients with acute respiratory failure (ARF), and particularly the lower inflection point (LIP) of the curve, we drew the total respiratory system, lung, and chest-wall P-V curves (P-Vrs, P-VL, and P-Vw, respectively) for 13 patients with ARF, using the supersyringe method together with the esophageal balloon technique. Measurements were randomly repeated at four different levels of positive end-expiratory pressure (PEEP) (0, 5, 10, 15 cm H₂O) and from each P-V curve we derived starting compliance (C_start), inflation compliance (C_inf), and end compliance (C_end). With PEEP of 0 cm H₂O (ZEEP), an LIP on the P-Vrs curve was observed in all patients (7.5 ± 3.9 cm H₂O); in two patients an LIP was detected only on the P-VL curve (8.6 and 8.7 cm H₂O, respectively); whereas in seven patients an LIP was observed only on the P-Vw curve (3.4 ± 1.1 cm H₂O). In four patients, an LIP was detected on both the P-VL and P-Vw curves (8.5 ± 3.4 and 2.2 ± 1.0 cm H₂O, respectively). The LIP was abolished by PEEP, suggesting that a volume-related mechanism was responsible for the observed LIP on both the P-VL and P-Vw curves. At high levels of PEEP, an upper inflection point (UIP) appeared on the P-Vrs and P-VL curves (11.7 ± 4.9 cm H₂O and 8.9 ± 4.2 cm H₂O above PEEP, respectively) suggesting alveolar overdistension. In general, Pa_O2 increased with PEEP (from 81.7 ± 35.5 mm Hg on ZEEP to 120 ± 43.8 mm Hg on PEEP 15 cm H₂O, p < 0.002); however, the increase in Pa_O2 with PEEP was significant only in patients with an LIP on the P-VL curve (from 70.5 ± 16.2 mm Hg to 117.5 ± 50.7 mm Hg, p < 0.002), the changes in Pa_O2 in patients without an LIP on the P-VL curve not being significant (from 91.3 ± 45.4 mm Hg to 122.2 ± 41.1 mm Hg). We conclude that in ventilator-dependent patients with ARF: (1) the chest-wall mechanics can contribute to the LIP observed on the P-Vrs curve; (2) the improvement in Pa_O2 with PEEP is significant only in patients in whom LIP is on the lung P-V curve and not on the chest wall curve; (3) high levels of PEEP may overdistend the lung, as reflected by the appearance of a UIP; (4) measurement of P-Vrs alone may be misleading as a guide for setting the level of PEEP in some mechanically ventilated patients, at least in the supine position, although it helps to prevent excessive alveolar overdistension by indicating the inflection volume above which UIP may appear.

This article has been cited by other articles:

				P. D. Macnaughton New ventilators for the ICU--usefulness of lung performance reporting Br. J. Anaesth., July 1, 2006; 97(1): 57 - 63. [Abstract] [Full Text] [PDF]

				F. Petak, W. Habre, B. Babik, J. Tolnai, and Z. Hantos Crackle-sound recording to monitor airway closure and recruitment in ventilated pigs. Eur. Respir. J., April 1, 2006; 27(4): 808 - 816. [Abstract] [Full Text] [PDF]

				G. R. Washko, C. R. O'Donnell, and S. H. Loring Volume-related and volume-independent effects of posture on esophageal and transpulmonary pressures in healthy subjects J Appl Physiol, March 1, 2006; 100(3): 753 - 758. [Abstract] [Full Text] [PDF]

				C. Pereira, J. Bohe, S. Rosselli, E. Combourieu, C. Pommier, J.-P. Perdrix, J.-C. Richard, M. Badet, S. Gaillard, F. Philit, et al. Sigmoidal equation for lung and chest wall volume-pressure curves in acute respiratory failure J Appl Physiol, November 1, 2003; 95(5): 2064 - 2071. [Abstract] [Full Text] [PDF]

				S.M. Maggiore, J-C. Richard, and L. Brochard What has been learnt from P/V curves in patients with acute lung injury/acute respiratory distress syndrome Eur. Respir. J., August 1, 2003; 22(42_suppl): 22s - 26s. [Abstract] [Full Text] [PDF]

				J-J. Rouby, Q. Lu, and S. Vieira Pressure/volume curves and lung computed tomography in acute respiratory distress syndrome Eur. Respir. J., August 1, 2003; 22(42_suppl): 27s - 36s. [Abstract] [Full Text] [PDF]

				I. de Chazal and R. D. Hubmayr Novel aspects of pulmonary mechanics in intensive care Br. J. Anaesth., July 1, 2003; 91(1): 81 - 91. [Full Text] [PDF]

				O. Stenqvist Practical assessment of respiratory mechanics Br. J. Anaesth., July 1, 2003; 91(1): 92 - 105. [Full Text] [PDF]

				A. Vieillard-Baron, F. Jardin, J.-J. Rouby, Q. Lu, and I. Goldstein Right level of positive end-expiratory pressure in acute respiratory distress syndrome Am. J. Respir. Crit. Care Med., June 1, 2003; 167(11): 1576 - 1577. [Full Text]

				W. L. Lee, T. E. Stewart, R. MacDonald, S. Lapinsky, D. Banayan, D. Hallett, and S. Mehta Safety of Pressure-Volume Curve Measurement in Acute Lung Injury and ARDS Using a Syringe Technique* Chest, May 1, 2002; 121(5): 1595 - 1601. [Abstract] [Full Text] [PDF]

				M. TAKEUCHI, K. A. SEDEEK, G. P. P. SCHETTINO, K. SUCHODOLSKI, and R. M. KACMAREK Peak Pressure During Volume History and Pressure-Volume Curve Measurement Affects Analysis Am. J. Respir. Crit. Care Med., October 1, 2001; 164(7): 1225 - 1230. [Abstract] [Full Text] [PDF]

				S. M. MAGGIORE, B. JONSON, J.-C. RICHARD, S. JABER, F. LEMAIRE, and L. BROCHARD Alveolar Derecruitment at Decremental Positive End-Expiratory Pressure Levels in Acute Lung Injury . Comparison with the Lower Inflection Point, Oxygenation, and Compliance Am. J. Respir. Crit. Care Med., September 1, 2001; 164(5): 795 - 801. [Abstract] [Full Text] [PDF]

				G. RIALP, A. J. BETBESE, M. PEREZ-MARQUEZ, and J. MANCEBO Short-term Effects of Inhaled Nitric Oxide and Prone Position in Pulmonary and Extrapulmonary Acute Respiratory Distress Syndrome Am. J. Respir. Crit. Care Med., July 15, 2001; 164(2): 243 - 249. [Abstract] [Full Text] [PDF]

				M. Mergoni, A. Volpi, C. Bricchi, and A. Rossi Lower inflection point and recruitment with PEEP in ventilated patients with acute respiratory failure J Appl Physiol, July 1, 2001; 91(1): 441 - 450. [Abstract] [Full Text] [PDF]

				S. CROTTI, D. MASCHERONI, P. CAIRONI, P. PELOSI, G. RONZONI, M. MONDINO, J. J. MARINI, and L. GATTINONI Recruitment and Derecruitment during Acute Respiratory Failure . A Clinical Study Am. J. Respir. Crit. Care Med., July 1, 2001; 164(1): 131 - 140. [Abstract] [Full Text] [PDF]

				K. G. HICKLING Best Compliance during a Decremental, But Not Incremental, Positive End-Expiratory Pressure Trial Is Related to Open-Lung Positive End-Expiratory Pressure . A Mathematical Model of Acute Respiratory Distress Syndrome Lungs Am. J. Respir. Crit. Care Med., January 1, 2001; 163(1): 69 - 78. [Abstract] [Full Text]

				M. Lichtwarck-Aschoff, V. Kessler, U. H. Sjostrand, A. Hedlund, G. Mols, S. Rubertsson, A. M. Markstrom, and J. Guttmann Static versus dynamic respiratory mechanics for setting the ventilator Br. J. Anaesth., October 1, 2000; 85(4): 577 - 586. [Abstract] [Full Text] [PDF]

				J. A. Krishnan and R. G. Brower High-Frequency Ventilation for Acute Lung Injury and ARDS Chest, September 1, 2000; 118(3): 795 - 807. [Abstract] [Full Text] [PDF]

				V. NÈVE, E. D. de la ROQUE, F. LECLERC, S. LETEURTRE, A. DORKENOO, A. SADIK, R. CREMER, and R. LOGIER Ventilator-induced Overdistension in Children . Dynamic versus Low-flow Inflation Volume-Pressure Curves Am. J. Respir. Crit. Care Med., July 1, 2000; 162(1): 139 - 147. [Abstract] [Full Text]

				The Acute Respiratory Distress Syndrome Network Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome N. Engl. J. Med., May 4, 2000; 342(18): 1301 - 1308. [Abstract] [Full Text] [PDF]

				International Consensus Conferences in Intensive Care Medicine: Ventilator-associated Lung Injury in ARDS . THIS OFFICIAL CONFERENCE REPORT WAS COSPONSORED BY THE AMERICAN THORACIC SOCIETY, THE EUROPEAN SOCIETY OF INTENSIVE CARE MEDICINE, AND THE SOCIETE DE REANIMATION DE LANGUE FRANCAISE, AND WAS APPROVED BY THE ATS BOARD OF DIRECTORS, JULY 1999 Am. J. Respir. Crit. Care Med., December 1, 1999; 160(6): 2118 - 2124. [Full Text]

				A. Vieillard-Baron, Y. Loubieres, J.-M. Schmitt, B. Page, O. Dubourg, and F. Jardin Cyclic changes in right ventricular output impedance during mechanical ventilation J Appl Physiol, November 1, 1999; 87(5): 1644 - 1650. [Abstract] [Full Text] [PDF]

				S. R. R. VIEIRA, L. PUYBASSET, Q. LU, J. RICHECOEUR, P. CLUZEL, P. CORIAT, and J.-J. ROUBY A Scanographic Assessment of Pulmonary Morphology in Acute Lung Injury . Significance of the Lower Inflection Point Detected on the Lung Pressure-Volume Curve Am. J. Respir. Crit. Care Med., May 1, 1999; 159(5): 1612 - 1623. [Abstract] [Full Text] [PDF]

				B. JONSON, J.-C. RICHARD, C. STRAUS, J. MANCEBO, F. LEMAIRE, and L. BROCHARD Pressure-Volume Curves and Compliance in Acute Lung Injury . Evidence of Recruitment Above the Lower Inflection Point Am. J. Respir. Crit. Care Med., April 1, 1999; 159(4): 1172 - 1178. [Abstract] [Full Text] [PDF]

				P. PELOSI, P. CADRINGHER, N. BOTTINO, M. PANIGADA, F. CARRIERI, E. RIVA, A. LISSONI, and L. GATTINONI Sigh in Acute Respiratory Distress Syndrome Am. J. Respir. Crit. Care Med., March 1, 1999; 159(3): 872 - 880. [Abstract] [Full Text]

				Q. LU, S. R. R. VIEIRA, J. RICHECOEUR, L. PUYBASSET, P. KALFON, P. CORIAT, and J.-J. ROUBY A Simple Automated Method for Measuring Pressure-Volume Curves during Mechanical Ventilation Am. J. Respir. Crit. Care Med., January 1, 1999; 159(1): 275 - 282. [Abstract] [Full Text]

				J. B. Hall Respiratory System Mechanics in Adult Respiratory Distress Syndrome . Stretching Our Understanding Am. J. Respir. Crit. Care Med., July 1, 1998; 158(1): 1 - 2. [Full Text] [PDF]

				L. GATTINONI, P. PELOSI, P. M. SUTER, A. PEDOTO, P. VERCESI, and A. LISSONI Acute Respiratory Distress Syndrome Caused by Pulmonary and Extrapulmonary Disease . Different Syndromes? Am. J. Respir. Crit. Care Med., July 1, 1998; 158(1): 3 - 11. [Abstract] [Full Text] [PDF]