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Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment

Departments of Surgery and Pathology, State University of New York Upstate Medical University, Syracuse, New York; and Department of Biological Sciences, State University of New York College at Cortland, Cortland, New York

Correspondence and requests for reprints should be addressed to Correspondence and requests for reprints should be addressed to Dr. Jeffrey M. Halter, M.D., SUNY Upstate Medical University, Department of Surgery, 750 E. Adams Street, Syracuse, NY 13210. E-mail: halterj{at}upstate.edu

We tested the hypothesis that collapsed alveoli opened by a recruitment maneuver would be unstable or recollapse without adequate positive end-expiratory pressure (PEEP) after recruitment. Surfactant deactivation was induced in pigs by Tween instillation. An in vivo microscope was placed on a lung area with significant atelectasis and the following parameters measured: (1) the number of alveoli per field and (2) alveolar stability (i.e., the change in alveolar size from peak inspiration to end expiration). We previously demonstrated that unstable alveoli cause lung injury. A recruitment maneuver (peak pressure = 45 cm H₂O, PEEP = 35 cm H₂O for 1 minute) was applied and alveolar number and stability were measured. Pigs were then separated into two groups with standard ventilation plus (1) 5 PEEP or (2) 10 PEEP and alveolar number and stability were again measured. The recruitment maneuver opened a significant number of alveoli, which were stable during the recruitment maneuver. Although both 5 PEEP and 10 PEEP after recruitment demonstrated improved oxygenation, alveoli ventilated with 10 PEEP were stable, whereas alveoli ventilated with 5 PEEP showed significant instability. This suggests recruitment followed by inadequate PEEP permits unstable alveoli and may result in ventilator-induced lung injury despite improved oxygenation.

Key Words: acute respiratory distress syndrome • alveolar mechanics • in vivo microscopy • recruitment maneuver • ventilator-induced lung injury

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