Recruitment Maneuver Does not Increase the Risk of Ventilator Induced Lung Injury

Yıl 2013, , 229 - 234, 01.02.2013

İbrahim Özkan Akıncı Korkut Atalan Simru Tuğrul Perihan Ergin Özcan Dilek Yılmazbayhan Bayram Kıran Ahmet Basel Lutfi Telci Nahit Çakar

https://doi.org/10.5152/balkanmedj.2013.7375

Öz

Background: Mechanical ventilation (MV) may induce lung injury. Aims: To assess and evaluate the role of different mechanical ventilation strategies on ventilator-induced lung injury (VILI) in comparison to a strategy which includes recruitment manoeuvre (RM). Study design: Randomized animal experiment. Methods: Thirty male Sprague-Dawley rats were anaesthetised, tracheostomised and divided into 5 groups randomly according to driving pressures; these were mechanically ventilated with following peak alveolar opening (Pao) and positive end-expiratory pressures (PEEP) for 1 hour: Group 15-0: 15 cmH2O Pao and 0 cmH2O PEEP; Group 30-10: 30 cmH2O Pao and 10 cmH2O PEEP; Group 30-5: 30 cmH2O Pao and 5 cmH2O PEEP; Group 30-5&RM: 30 cmH2O Pao and 5 cmH2O PEEP with additional 45 cmH2O CPAP for 30 seconds in every 15 minutes; Group 45-0: 45 cmH2O Pao and 0 cmH2O PEEP Before rats were sacrificed, blood samples were obtained for the evaluation of cytokine and chemokine levels; then, the lungs were subsequently processed for morphologic evaluation. Results: Oxygenation results were similar in all groups; however, the groups were lined as follows according to the increasing severity of morphometric evaluation parameters: Group 15-0: (0±0.009) < Group 30-10: (0±0.14) < Group 30-5&RM: (1±0.12) < Group 30-5: (1±0.16) < Group 45-0: (2±0.16). Besides, inflammatory responses were the lowest in 30-5&RM group compared to all other groups. TNF-α, IL-1β, IL-6, MCP-1 levels were significantly different between group 30-5&RM and group 15-0 vs. group 45-0 in each group. Conclusion: RM with low PEEP reduces the risk of ventilator-induced lung injury with a lower release of systemic inflammatory mediators in response to mechanical ventilation. Turkish Başlık: Yeniden Kazandırma Manevrası Ventilatör İlişkili Akciğer Hasarı Riskini Artırmaz Arka Plan: Mekanik ventilasyon (MV) akciğer hasarına neden olabilir. Amaç: Farklı MV stratejilerinin ventilatör ilişkili akciğer hasarı üzerine etkilerini kazandırma manevrasını (RM) da içeren bir ventilasyon stratejisiyle karşılaştırarak değerlendirmek. Çalışma Tasarımı: Randomize hayvan çalışması. Yöntemler: Otuz erkek Sprague-Dawley sıçanı, anestezi uygulamasını takiben trakeostomize edildi ve uygulanacak ventilatör basınçlarına göre rastgele 5 gruba ayrılarak 1 saat süreyle aşağıdaki peak alveoler basınç (Pao) ve pozitif ekspiryum sonu basınç (PEEP) değerleriyle ventile edildiler. Grup 15-0: 15 cmH2O Pao ve 0 cm H2O PEEP; Grup 30-10: 30 cmH2O Pao ve 10 cmH2O PEEP; Grup 30-5: 30 cmH2O Pao ve 5 cmH2O PEEP; Grup 30-5&RM: 30 cmH2O Pao ve 5 cmH2O PEEP'e ek olarak her 15 dakikada bir 30 saniye süreli 45 cmH2O CPAP; Grup 45-0: 45 cmH2O Pao ve 0 cmH2O PEEP Sıçanlar sakrifiye edilmeden önce sitokin ve kemokin düzeylerinin değerlendirilmesi için kan örnekleri alındı. Sonrasında akciğerler morfolojik değerlendirme için işleme tabi tutuldu. Bulgular: Oksijenasyon sonuçları tüm gruplarda benzerdi, ancak morfometrik değerlendirme parametrelerinin artan şiddetine göre gruplar şu şekilde sıralandı. Grup 15-0: (0±0.009) < Grup 30-10: (0±0.14) < Grup 30-5&RM: (1±0.12) < Grup 30-5: (1±0.16) < Grup 45-0: (2±0.16). Bununla birlikte, diğer gruplarla kıyaslandığında inflamatuar yanıt 30-5&RM grubunda en düşüktü. TNF-a, IL-1 b, IL-6, MCP-1 seviyeleri grup 30-5&RM ve grup 15-0' da grup 45-0 ile kıyaslandıklarında anlamlı farklılık gösterdi. Sonuç: Düşük PEEP'le birlikte RM, MV'a yanıt olarak salınan sistemik inflamatuar

Anahtar Kelimeler

Recruitment manoeuvre, ventilator-induced lung injury, TNF-α, IL-1β, IL-6, MCP-1

Recruitment Maneuver Does not Increase the Risk of Ventilator Induced Lung Injury

Öz

Kaynakça

• International consensus conferences in intensive care medicine. Ventilator-associated lung injury in ARDS. American Thoracic Society, European Society of Intensive Care Medicine, Societé de Réanimation Langue Française. Intensive Care Med 1999;25:1444-52.
• Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000;342:1301-8. [CrossRef]
• Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, et al. Effect of protective ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 1998;338:347-54. [CrossRef]
• Stewart TE, Meade MO, Cook DJ, Granton JT, Hodder RV, Lapinsky SE, et al. Evaluation of a ventilation strategy to prevent barotrauma in patients at high risk for acute respiratory distress syndrome. Pressure- and Volume-Limited Ventilation Strategy Group. N Engl J Med 1998;338:355-61. [CrossRef]
• Brochard L, Roudot-Thoraval F, Roupie E, Delclaux C, Chastre J, Fernandez-Mondéjar E, et al. Tidal volume reduction for prevention of ventilator-induced lung injury in acute respiratory distress syndrome. The Multicenter Trail Group on Tidal Volume reduction in ARDS. Am J Respir Crit Care Med 1998;158:1831-8. [CrossRef]
• Pelosi P, Cadringher P, Bottino N, Panigada M, Carrieri F, Riva E, et al. Sigh in acute respiratory distress syndrome. Am J Respir Crit Care Med 1999;159:872-80. [CrossRef]
• Cakar N, der Kloot TV, Youngblood M, Adams A, Nahum A. Oxygenation response to a recruitment maneuver during supine and prone positions in an oleic-acid lung injury model. Am J Respir Crit Care Med 2000;161:1949-56. [CrossRef]
• Muscedere JG, Mullen JB, Gan K, Slutsky AS. Tidal ventilation at low airway pressures can augment lung injury. Am J Respir Crit Care Med 1994;149:1327-34. [CrossRef]
• Lapinsky SE, Aubin M, Mehta S, Boiteau P, Slutsky AS. Safety and efficacy of a sustained inflation for alveolar recruitment in adults with respiratory failure. Int Care Med 1999;25:1295-301. [CrossRef]
• Rimensberger PC, Pristine G, Mullen BM, Cox PN, Slutsky AS. Lung recruitment during small tidal volume ventilation allows minimal positive end-expiratory pressure without augmenting lung injury. Crit Care Med 1999;27:1940-5. [CrossRef]
• Gattinoni L, Pelosi P, Vitale G, Pesenti A, D’Andrea L, Mascheroni D. Body position changes redistribute lung computed-tomographic density in patients with acute respiratory failure. Anesthesiology 1991;74:15-23. [CrossRef]
• Cakar N, Akinci O, Tugrul S, Ozcan PE, Esen F, Eraksoy H, et al. Recruitment maneuver: does it promote bacterial translocation? Crit Care Med 2002;30:2103-6. [CrossRef]
• Dreyfuss D, Basset G, Soler P, Saumon G. Intermittent positivepressure hyperventilation with high inflation pressures produces pulmonary microvascular injury in rats. Am Rev Respir Dis 1985;132:880-4.
• Webb HH, Tierney DF. Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressures: protection by positive end-expiratory pressure. Am Rev Respir Dis 1974;110:556-65.
• John E, Ermocilla R, Golden J, McDevitt M, Cassady G. Effects of intermittent positive-pressure ventilation on lungs of normal rabbits. Br J Exp Pathol 1980;61:315-23.
• Kloot TE, Blanch L, Melynne Youngblood A, Weinert C, Adams AB, Marini JJ, et al. Recruitment maneuvers in three experimental models of acute lung injury. Effect on lung volume and gas exchange. Am J Respir Crit Care Med 2000;161:1485-94. [CrossRef] Grasso S, Mascia L, Del Turco M, Malacarne P, Giunta F, Brochard L, et al. Effect of recruiting maneuvers in patients with acute respiratory distress syndrome ventilated with protective ventilatory strategy. Anesthsiology 2002;96:795-802. [CrossRef]
• Ko SC, Zhang H, Haitsma JJ, Cheng KC, Li CF, Slutsky AS. Effects of PEEP levels following repeated recruitment maneuvers on ventilator-induced lung injury. Acta Anaesthesiol Scand 2008;52:514-21. [CrossRef]
• Naik AS, Kallapur SG, Bachurski CJ, Jobe AH, Michna J, Kramer BW, et al. Effects of ventilation with different positive end-expiratory pressures on cytokine expression in the preterm lamb lung. Am J Respir Crit Care Med 2001;164:494-8. [CrossRef]
• Pittet JF, Mackersie RC, Martin TR, Matthay MA. Biological markers of acute lung injury: prognostic and pathogenetic significance. Am J Respir Crit Care Med 1997;155:1187-205. [CrossRef]
• Ranieri VM, Suter PM, Tortorella C, De Tullio R, Dayer JM, Brienza A, et al. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial. JAMA 1999;282:54-61. [CrossRef]
• Muscedere JG, Mullen JB, Gan K, Slutsky AS. Tidal ventilation at low airway pressures can augment lung injury. Am J Respir Crit Care Med 1994;149:1327-34. [CrossRef]
• Tremblay L, Valenza F, Ribeiro SP, Li J, Slutsky AS. Injurious ventivlatory strategies increase cytokines and c-fos m-RNA expression in an isolated rat lung model. J Clin Invest 1997;99:944-52. [CrossRef]
• Goodman RB, Strieter RM, Martin DP, Steinberg KP, Milberg JA, Maunder RJ, et al. Inflammatory cytokines in patients with persistence of the acute respiratory distress syndrome. Am J Respir Crit Care Med 1996;154:602-11. [CrossRef]
• Nicholas TE, Power JHT, Barr HA. The pulmonary consequences of a deep breath. Respir Physiol 1982;49:315-24. [CrossRef]
• Dreyfuss D, Saumon G. Ventilator-induced lung injury: lessons from experimental studies. Am J Respir Crit Care Med 1998;157:294-323. [CrossRef]
• Seah AS, Grant KA, Aliyeva M, Allen GB, Bates JH. Quantifying the Roles of Tidal Volume and PEEP in the Pathogenesis of Ventilator-Induced Lung Injury. Ann Biomed Eng 2011;39: 1505[CrossRef]
• Van Marter LJ, Allred EN, Pagano M, Sanocka U, Parad R, Moore M, et al. Do clinical markers of barotrauma and oxygen toxicity explain interhospital variation in rates of chronic lung disease? The Neonatology Committee for the Developmental Network. Pediatrics 2000;105:1194-201. [CrossRef]