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Am. J. Respir. Crit. Care Med., Volume 164, Number 1, July 2001, 122-130

Recruitment and Derecruitment During Acute Respiratory Failure
An Experimental Study

PAOLO PELOSI, MARI GOLDNER, ANDREW McKIBBEN, ALEX ADAMS, GIUDITTA ECCHER, PIETRO CAIRONI, SABINA LOSAPPIO, LUCIANO GATTINONI, and JOHN J. MARINI

Istituto di Anestesia e Rianimazione, Università degli Studi di Milano, Ospedale Maggiore Policlinico-IRCCS, Milan, Italy; and Department of Pulmonary and Critical Care Medicine, University of Minnesota, Regions Hospital, St. Paul, Minnesota

We aimed to elucidate the relationships between pleural (Ppl), esophageal (Pes), and superimposed gravitational pressures in acute lung injury, and to understand the mechanisms of recruitment and derecruitment. In six dogs with oleic acid respiratory failure, we measured Pes and Ppl in the uppermost, middle, and most dependent lung regions. Each dog was studied at positive end-expiratory pressure (PEEP) of 5 and 15 cm H2O and three levels of tidal volume (VT; low, medium, and high). For each PEEP-VT combination, we obtained a computed tomographic (CT) scan at end-inspiration and end-expiration. The variations of Ppl and Pes pressures were correlated (r = 0.86 ± 0.07, p < 0.0001), as was the vertical gradient of transpulmonary (PL) and superimposed pressure (r = 0.92, p < 0.0001). Recruitment proceeded continuously along the entire volume-pressure curve. Estimated threshold opening pressures were normally distributed (mode = 20 to 25 cm H2O). The amount of end-expiratory collapse at the same PEEP and PL was significantly lower when ventilation was performed at high VT. End-inspiratory and end-expiratory collapse were highly correlated (r = 0.86, p < 0.0001), suggesting that as more tissue is recruited at end-inspiration, more remains recruited at end-expiration. When superimposed pressure exceeded applied airway pressure (Paw), collapse significantly increased.

Keywords: ALI/ARDS; oleic acid; mechanical ventilation; computed tomography; volume pressure curve




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