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Original Research ARTICLE Provisionally accepted The full-text will be published soon. Notify me

Front. Physiol. | doi: 10.3389/fphys.2019.01392

The Effects Of Positive End-expiratory Pressure On Transpulmonary Pressure And Recruitment-derecruitment During Neurally Adjusted Ventilator Assist. A continuous computed tomography study in an animal model of acute respiratory distress syndrome.

Carl H. Widing1, 2,  Mariangela Pellegrini3, Anders S. Larsson1 and  Gaetano Perchiazzi4*
  • 1Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Sweden
  • 2Norra Älvsborgs Länssjukhus, Sweden
  • 3Hedenstierna Laboratory - Dept. of Surgical Sciences and Intensive Care Units of Uppsala University Hospital , Uppsala , Sweden, Uppsala University, Sweden
  • 4Hedenstierna Laboratory - Dept. of Surgical Sciences and Intensive Care Units of Uppsala University Hospital, Uppsala University, Sweden

Background: Whether spontaneous breathing should be used in early acute respiratory distress syndrome (ARDS) is questioned, as it may cause ventilator induced lung injury (VILI), by tidal high strain/stress and recruitment/derecruitment. However, spontaneous breathing has shown beneficial effects, when used appropriately. We hypothesized that high levels of positive end-expiratory pressure (PEEP), during assisted spontaneous breathing, would prevent tidal recruitment/derecruitment (R/D), reducing ventilatory variation and respiratory rate, while potentially increasing transpulmonary pressure. The aim was to test this hypothesis in experimental mild ARDS during continuous spontaneous breathing, using neurally adjusted ventilator assist (NAVA) and uninterrupted computed tomography (CT) exposure.
Methods: Mild experimental ARDS (PaO2/FiO2-ratio of 250) was induced in anesthetised pigs (n=5), ventilated using uninterrupted NAVA. PEEP was changed in steps of 3 cmH2O, from 0 to 15 and back to 0 cmH2O. Dynamic CT scans, ventilatory parameters and oesophageal pressure were acquired simultaneously. Transpulmonary pressure (PTP) and R/D were calculated and compared amongst PEEP levels.
Results: When increasing PEEP from 0 to 15 cmH2O, tidal R/D decreased from 4.3±5.9% to 1.1±0.7% (p < 0.01), breath-to-breath variability decreased, while PTP increased from 11.4±3.7 to 29.7±14.1 cmH2O (R² = 0.96).
Conclusions: This study shows that injurious phenomena like R/D and high PTP are present in NAVA at the two extrema of the PEEP spectrum. Willing to titrate PEEP in order to limit these phenomena, the physician must choose the best compromise between restraining the recruitment-derecruitment or the transpulmonary pressure.

Keywords: ARDS (Acute respiratory distress syndrome), VILI (Ventilator Induced Lung Injury), NAVA (neurally adjusted ventilatory assist), respiratory failure, PEEP (positive end-expiratory pressure)

Received: 19 Jul 2019; Accepted: 28 Oct 2019.

Copyright: © 2019 Widing, Pellegrini, Larsson and Perchiazzi. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Mx. Gaetano Perchiazzi, Uppsala University, Hedenstierna Laboratory - Dept. of Surgical Sciences and Intensive Care Units of Uppsala University Hospital, Uppsala, Sweden,