Published ahead of print on January 21, 2005, doi:10.1164/rccm.200407-940OC
Am. J. Respir. Crit. Care Med., Volume 171, Number 9, May 2005, 1002-1008
A more recent version of this article appeared on May 1, 2005
Submitted on July 23, 2004
Accepted on January 18, 2005
Effects of High versus Low Positive End-Expiratory Pressure in Acute Respiratory Distress Syndrome
Salvatore Grasso1*, Vito Fanelli2, Aldo Cafarelli3, Roberto Anaclerio3, Marilisa Amabile2, Giovanni Ancona3, and Tommaso Fiore2
1 Servizio di Anestesia e Rianimazione, Azienda Sanitaria Locale (ASL) Bari 4, Ospedale Di Venere, Bari, Italy; Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia, Universita degli Studi di Bari, Bari, Italy,
2 Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia, Universita degli Studi di Bari, Bari, Italy,
3 Servizio di Anestesia e Rianimazione, Azienda Sanitaria Locale (ASL) Bari 4, Ospedale Di Venere, Bari, Italy
* To whom correspondence should be addressed. E-mail: grassos{at}libero.it.
A recent study by the Acute Respiratory Distress Syndrome Network compared the traditional lower end-expiratory pressure strategy with a higher end-expiratory pressure one in patients with the acute respiratory distress syndrome ventilated with low tidal volumes. Clinical outcomes were similar whether lower or higher positive end-expiratory pressure levels were used. We applied both the lower (9 ± 2 cmH2O) and higher (16 ± 1 cmH2O) positive end-expiratory pressure strategy in 19 patients. In 9 recruiters the higher end-expiratory pressure strategy resulted in significant alveolar recruitment (587 ± 158 ml), improvement in arterial oxygen partial pressure/inspired oxygen fraction ratio (from 150 ± 36 to 396 ± 138) and reduction in static lung elastance (from 23 ± 3 to 20 ± 2 cmH2O/L). In 10 non recruiters alveolar recruitment was minimal, oxygenation did not improve and static lung elastance significantly increased (from 26 ± 5 to 28 ± 6 cmH2O/L). The increase in oxygenation, the reduction in static lung elastance and the shape of the volume-pressure curve during the lower positive end-expiratory pressure strategy were independently associated with alveolar recruitment. In conclusion, the protocol proposed by the Acute Respiratory Distress Syndrome Network, lacking solid physiological basis, frequently fails to induce alveolar recruitment and may increase the risk of alveolar overinflation.
Key words: ARDS, human; Respiratory Distress Syndrome, adult/therapy, Positive-Pressure Respiration/methods
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