Published ahead of print on October 12, 2006, doi:10.1164/rccm.200607-915OC
Am. J. Respir. Crit. Care Med., Volume 175, Number 2, January 2007, 160-166
A more recent version of this article appeared on January 15, 2007
Submitted on July 6, 2006
Accepted on October 11, 2006
Tidal Hyperinflation During Low Tidal Volume Ventilation in Acute Respiratory Distress Syndrome
Pier Paolo Terragni1, Giulio Rosboch1, Andrea Tealdi1, Eleonora Corno1, Eleonora Menaldo1, Ottavio Davini2, Giovanni Gandini2, Peter Herrmann3, Luciana Mascia1, Michel Quintel3, Arthur S Slutsky4, Luciano Gattinoni5, and V. Marco Ranieri1*
1 Ospedale S. Giovanni Battista-Molinette, Dipartimento di Anestesiologia e Rianimazione, Universita di Torino, Torino, Italy,
2 Ospedale S. Giovanni Battista-Molinette, Dipartimento di Radiologia, Universita di Torino, Torino, Italy,
3 Department of Anesthesiology, University of Gottingen, Gottingen, Germany,
4 St. Michael's Hospital, Division of Respiratory Medicine, Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada,
5 Fondazione IRCCS - "Ospedale Maggiore Policlinico, Mangiagalli, Regina Elena" di Milano, Istituto di Anestesia e Rianimazione, Universita degli Studi di Milano, Italy
* To whom correspondence should be addressed. E-mail: marco.ranieri{at}unito.it.
Rationale: Tidal volume and plateau pressure limitation decreases mortality in ARDS. Computed tomography demonstrated a small normally aerated compartment on the top of poorly aerated, and non-aerated compartments that may be hyperinflated by tidal inflation.
Objectives: We hypothesized that despite tidal volume and plateau pressure limitation, patients with larger non-aerated compartment are exposed to tidal hyperinflation of the normally aerated compartment.
Measurements and Main Results: Pulmonary computed tomography at end-expiration and end-inspiration was obtained in 30 patients ventilated with a low tidal volume (6 ml/kg predicted body weight). Cluster analysis identified 20 patients where tidal inflation largely occurred in the normally aerated compartment (69.9 ±6.9 %; "more protected"), and 10 patients where tidal inflation largely occurred within the hyperinflated compartments (63.0 ± 12.7 %; "less protected" ). The non-aerated compartment was smaller and the normally aerated compartment larger in the "more protected" than in "less protected" (P = 0.01). Pulmonary cytokines were lower in the "more protected" than in the "less protected" (P < 0.05). Ventilator free days were 7 ± 8 and 1 ± 2 in the "more protected" and "less protected", respectively (P = 0.01). Plateau pressure in "more protected" ranged between 25 and 26 cm H2O and in "less protected" between 28 and 30 cm H2O (P = 0.006).
Conclusions: Limiting tidal volume to 6 ml/kg PBW and plateau pressure to 30 cm H2O may not be sufficient in patients characterized by a larger non-aerated compartment.
Key words: Acute Lung Injury, inflammatory response, mechanical ventilation, VILI
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Copyright © 2006 American Thoracic Society
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