Published ahead of print on May 11, 2006, doi:10.1164/rccm.200506-976OC
Am. J. Respir. Crit. Care Med., Volume 174, Number 3, August 2006, 268-278
A more recent version of this article appeared on August 1, 2006
Submitted on June 24, 2005
Accepted on May 10, 2006
Reversibility of Lung Collapse and Hypoxemia in Early Acute Respiratory Distress Syndrome
Joao B Borges1, Valdelis N Okamoto1, Gustavo F.J. Matos1, Maria P.R. Caramez2, Paula R Arantes3, Fabio Barros1, Ciro E Souza1, Josue A Victorino1, Robert M Kacmarek4, Carmen S.V. Barbas1, Carlos R.R. Carvalho1, and Marcelo B.P. Amato1*
1 Respiratory ICU, Pulmonary Department, University of Sao Paulo, Hospital das Clinicas, Sao Paulo, Sao Paulo, Brazil,
2 General ICU, Emergency Clinics Division, University of Sao Paulo, Hospital das Clinicas, Sao Paulo, Sao Paulo, Brazil,
3 Radiology Department, University of Sao Paulo, Hospital das Clinicas, Sao Paulo, Sao Paulo, Brazil,
4 Department of Respiratory Care, Massachusetts General Hospital, Boston, Massachusetts, USA
* To whom correspondence should be addressed. E-mail: amato{at}unisys.com.br.
Rationale
The hypothesis that lung collapse is detrimental during the acute-respiratory-distress-syndrome is still debatable. One of the difficulties is the lack of an efficient maneuver to minimize it.
Objectives
To test if a bedside recruitment strategy, capable to reverse hypoxemia and collapse in > 95% of lung units, is clinically applicable in early acute-respiratory-distress-syndrome.
Methods
Prospective assessment of a stepwise maximum-recruitment strategy using multislice computerized tomography and continuous blood-gas/hemodynamic monitoring.
Measurements and Main Results
Twenty-six patients received sequential increments in inspiratory airway pressures, in 5 cmH2O steps, until the detection of PaO2 + PaCO2  400 mmHg. Whenever this primary target was not met, despite inspiratory pressures reaching 60 cmH2O, the maneuver was considered incomplete. In case of hemodynamic deterioration or barotrauma, the maneuver was to be interrupted. Late assessment of recruitment efficacy was performed by computerized-tomography (9 patients) or by on-line continuous monitoring in the ICU (15 patients) up to 6 hours.
It was possible to open the lung and to keep the lung open in the majority (24/26) of patients, at the expense of transient hemodynamic effects and hypercapnia, but without major clinical consequences. No barotrauma directly associated with the maneuver was detected. There was a strong and inverse relationship between arterial oxygenation and percentage of collapsed lung mass (R = - 0.91; P < 0.0001).
Conclusions
It is often possible to reverse hypoxemia and fully recruit the lung in early acute-respiratory-distress-syndrome. Due to transient side-effects the required maneuver still waits further evaluation before routine clinical application.
Key words: recruitment strategy; pulmonary shunt; mechanical ventilation; acute lung injury; positive end-expiratory pressure.
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Copyright © 2006 American Thoracic Society
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