Am. J. Respir. Crit. Care Med., Volume 164, Number 5, September 2001, 795-801

Alveolar Derecruitment at Decremental Positive End-Expiratory Pressure Levels in Acute Lung Injury
Comparison with the Lower Inflection Point, Oxygenation, and Compliance

SALVATORE M. MAGGIORE, BJÖRN JONSON, JEAN-CHRISTOPHE RICHARD, SAMIR JABER, FRANÇOIS LEMAIRE, and LAURENT BROCHARD

Medical Intensive Care Unit, INSERM U492, Henri Mondor Teaching Hospital, AP-HP, Paris XII University, Créteil, France; and Department of Clinical Physiology, Lund University Hospital, Lund, Sweden

We examined the hypothesis that recording multiple elastic pressure-volume (Pel/V) curves and calculating alveolar derecruitment (V_DER) induced by decreasing positive end-expiratory pressure (PEEP) may allow determination of alveolar closing pressures, thus helping to select the optimal PEEP level. V_DER measured in 16 patients with acute lung injury (ALI) was compared with the lower inflection point (LIP) and oxygenation changes. A modified automated method was used to record multiple Pel/V curves at low constant flow. PEEP was decreased in 5-cm H₂O steps, from 20 or 15 cm H₂O to 0 cm H₂O (ZEEP). V_DER was the volume loss between the curves recorded from PEEP and from ZEEP at the same Pel. Derecruitment occurred at each PEEP decrement, being spread almost uniformly over the 20/15 to 0 cm H₂O range. V_DER was not correlated with LIP. V_DER changes correlated with Pa_O2/FI_O2 changes (rho = 0.6, p = 0.02). Linear compliance at ZEEP was correlated to V_DER at PEEP 15 cm H₂O (rho = 0.9, p = 0.001), suggesting that compliance above LIP may reflect the amount of recruitable lung. Thus, alveolar closure in ALI occurs over a wide range of pressures, and LIP is a poor predictor of alveolar closure.

Keywords: PEEP; derecruitment; elastic pressure-volume curves; lower inflection point; acute lung injury

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