Am. J. Respir. Crit. Care Med., Volume 158, Number 1, July 1998, 194-202

The Pressure-Volume Curve Is Greatly Modified by Recruitment
A Mathematical Model of ARDS Lungs

KEITH G. HICKLING

Intensive Care Unit and Department of Anaesthesia, Queen Elizabeth Hospital, Kowloon; and Department of Anesthesia and Intensive Care, Chinese University of Hong Kong, Hong Kong

A mathematical model of the ARDS lung, with simulated gravitational superimposed pressure, evaluated the effect of varying alveolar threshold opening pressures (TOP), PEEP and peak inspiratory pressure (PIP) on the static pressure-volume (PV) curve. The lower inflection point (Pflex) was affected by SP and TOP, and did not accurately indicate PEEP required to prevent end-expiratory collapse. Reinflation of collapsed lung units (recruitment) continued on the linear portion of the PV curve, which had a slope at any volume greater than the total compliance of aerated alveoli. As recruitment diminished, the reduced PV slope could produce an upper Pflex at 20 to 30 cm H₂O pressure. An upper Pflex caused by alveolar overdistension could be modified or eliminated by recruitment with high TOP. With constant PIP as PEEP increased, and TOP range of 5 to 60 cm H₂O, PEEP to prevent end-expiratory collapse was indicated by minimum PV slope above 20 cm H₂O, minimum hysteresis, and maximum volume at a pressure of 20 cm H₂O. With constant inflation volume as PEEP increased, the effect on PV slope was unpredictable. Although increased PV slope indicated recruitment, maximum PV slope usually underestimated PEEP required to prevent end-expiratory collapse. Therefore, with this model the PV curve did not reliably predict optimal ventilator settings.

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