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Published ahead of print on May 1, 2008, doi:10.1164/rccm.200710-1589OC

Am. J. Respir. Crit. Care Med., Volume 178, Number 4, August 2008, 346-355

A more recent version of this article appeared on August 15, 2008
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Submitted on October 29, 2007
Accepted on May 1, 2008

Lung Stress and Strain During Mechanical Ventilation of the Acute Respiratory Distress Syndrome

Davide Chiumello1, Eleonora Carlesso2, Paolo Cadringher2, Pietro Caironi3, Franco Valenza3, Federico Polli2, Federica Tallarini2, Paola Cozzi2, Massimo Cressoni2, Angelo Colombo1, John J Marini4, and Luciano Gattinoni3*

1 Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS - "Ospedale Maggiore Policlinico Mangiagalli Regina Elena", Milan, Italy, 2 Istituto di Anestesiologia e Rianimazione, Fondazione IRCCS - "Ospedale Maggiore Policlinico Mangiagalli Regina Elena" di Milano, Italy; Universita degli Studi, Milan, Italy, 3 Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS - "Ospedale Maggiore Policlinico Mangiagalli Regina Elena", Milan, Italy; Istituto di Anestesiologia e Rianimazione, Fondazione IRCCS - "Ospedale Maggiore Policlinico Mangiagalli Regina Elena" di Milano, Italy; Universita degli Studi, Milan, Italy, 4 Pulmonary and Critical Care, University of Minnesota (Regions Hospital), St. Paul, Minnesota, USA

* To whom correspondence should be addressed. E-mail: gattinon{at}policlinico.mi.it.

Rationale: Lung injury due to ventilator results from un-physiological lung stress (transpulmonary pressure) and strain (inflated volume to functional residual capacity ratio). Objective: To determine whether the plateau pressure and the tidal volume are adequate surrogates for stress and strain. To quantify the stress to strain relationship in patients and control subjects. Methods: Nineteen post-surgical healthy patients (group 1), 11 patients with medical diseases (group 2), 26 patients with acute lung injury (group 3) and 24 patients with ARDS (group 4) underwent a PEEP trial (5 and 15 cmH2O) with 6, 8, 10 and 12 mL/kg tidal volume. Measurements and Main Results: plateau airway pressure, lung and chest wall elastances, lung stress and strain significantly increased from group 1 to 4 and increasing PEEP and tidal volume. Within each group a given applied airway pressure produced largely variable stress due to the variability of the lung elastance to respiratory system elastance ratio (range 0.33-0.95). Analogously for the same applied tidal volume the strain variability within subgroups was remarkable, due to the functional residual capacity variability. Therefore low or high tidal volume as 6 and 12 mL/kg could produce similar stress and strain in a remarkable fraction of patients in each subgroup. In contrast, the stress to strain ratio, i.e. specific lung elastance, was similar throughout the subgroups (13.4±3.4, 12.6±3.0, 14.4±3.6 and 13.5±4.1 cmH2O, P=0.58) and did not change with PEEP and tidal volume. Conclusions: Plateau pressure and tidal volume are inadequate surrogates for lung stress and strain. Clinical Trial Registry Information: ID# NCT00143468 at www.clinicaltrials.gov
Key words: Acute Respiratory Distress Syndrome; Acute Lung Injury; Stress, Mechanical; Strain; Ventilator Induced Lung Injury




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