Log in | Register

Scanographic comparison of high frequency oscillation with versus without tracheal gas insufflation in acute respiratory distress syndrome

Spyros D. Mentzelopoulos| Maria Theodoridou| Sotirios Malachias| Sotiris Sourlas| Demetrios N. Exarchos| Demetrios Chondros| Charis Roussos| Spyros G. Zakynthinos
Original
Volume 37, Issue 6 / June , 2011

Pages 990 - 999

Abstract

Purpose

In acute respiratory distress syndrome (ARDS), combined high frequency oscillation (HFO) and tracheal gas insufflation (TGI) improves oxygenation versus standard HFO, likely through TGI-induced lung recruitment. Experimental data suggest that steady flows such as TGI favor the filling of the lower (i.e., subcarinal) lung. We used whole-lung computerized tomography (CT) to determine whether HFO-TGI versus HFO improves the recruitment of the lower lung, and especially of its dependent region, where loss of aeration is maximized in ARDS.

Methods

We enrolled 15 patients who had ARDS for 96 h or less, and pulmonary infiltrates in at least three chest X-ray quadrants. Patients were subjected to whole-lung CT after lung-protective conventional mechanical ventilation (CMV) and after 45 min of HFO and 45 min of HFO-TGI. HFO/HFO-TGI were employed in random order. CT scans were obtained at a continuous positive airways pressure equal to the mean tracheal pressure (Ptr) of CMV. During HFO/HFO-TGI, mean airway pressure was titrated to the CMV Ptr level. Gas exchange and intra-arterial pressure/heart rate were determined for each ventilatory technique.

Results

Regarding total lung parenchyma, HFO-TGI versus HFO and CMV resulted in a lower percentage of nonaerated lung tissue (mean ± SD, 51.4 ± 5.1% vs. 60.0 ± 2.5%, and 62.1 ± 9.0%, respectively; P ≤ 0.04); this was due to HFO-TGI-induced recruitment of nonaerated tissue in the dependent and nondependent lower lung. HFO-TGI increased normally aerated tissue versus CMV (P = 0.04) and poorly aerated tissue versus HFO and CMV (P ≤ 0.04), and improved oxygenation versus HFO and CMV (P ≤ 0.04).

Conclusions

HFO-TGI improves oxygenation versus HFO and CMV through the recruitment of previously nonaerated lower lung units.

Keywords

References

  1. Mentzelopoulos SD, Roussos C, Koutsoukou A, Sourlas S, Malachias S, Lachana A, Zakynthinos SG (2007) Acute effects of combined high-frequency oscillation and tracheal gas insufflation in severe acute respiratory distress syndrome. Crit Care Med 35:1500–1508
    • View reference on PubMed
    • View reference on publisher's website
  2. Dolan S, Derdak S, Solomon D, Farmer C, Johanningman J, Gelineau J, Smith RB (1996) Tracheal gas insufflation combined with high-frequency oscillatory ventilation. Crit Care Med 24:456–465
    • View reference on publisher's website
  3. Mentzelopoulos SD, Malachias S, Kokkoris S, Roussos C, Zakynthinos SG (2010) Comparison of high-frequency oscillation and tracheal gas insufflation versus standard high-frequency oscillation at two levels of tracheal pressure. Intensive Care Med 36:810–816
  4. Nahum A (1998) Equipment review: tracheal gas insufflation. Crit Care 2:43–47
    • View reference on PubMed
    • View reference on publisher's website
  5. Slutsky AS, Berdine GG, Drazen JM (1980) Steady flow in a model of human central airways. J Appl Physiol 49:417–423
    • View reference on PubMed
  6. Puybasset L, Cluzel P, Chao N, Slutsky AS, Coriat P, Rouby JJ, CT Scan ARDS Study Group (1998) A computed tomography scan assessment of regional lung volume in acute lung injury. Am J Respir Crit Care Med 158:1644–1655
    • View reference on PubMed
  7. Malbuisson LM, Busch CJ, Puybasset L, Lu Q, Cluzel P, Rouby JJ, CT Scan ARDS Study Group (2000) Role of the heart in the loss of aeration characterizing lower lobes in acute respiratory distress syndrome. Am J Respir Crit Care Med 161:2005–2012
  8. Rouby JJ, Puybasset L, Nieszkowska A, Lu Q (2003) Acute respiratory distress syndrome: lessons from computed tomography of the whole lung. Crit Care Med 31(Suppl):S285–S295
    • View reference on PubMed
    • View reference on publisher's website
  9. Gattinoni L, Caironi P, Pelosi P, Goodman LR (2001) What has computed tomography taught us about the acute respiratory distress syndrome? Am J Respir Crit Care Med 164:1701–1711
    • View reference on PubMed
  10. Solway J, Rossing TH, Saari AF, Drazen JM (1986) Expiratory flow and dynamic pulmonary hyperinflation during high-frequency ventilation. J Appl Physiol 60:2071–2078
    • View reference on PubMed
  11. Luecke T, Herrmann P, Kraincuk P, Pelosi P (2005) Computed tomography scan assessment of lung volume and recruitment during high-frequency oscillation. Crit Care Med 33(Suppl):S155–S162
    • View reference on PubMed
    • View reference on publisher's website
  12. Malbuisson LM, Muller JC, Constantin JM, Lu Q, Puybasset L, Rouby JJ, CT Scan ARDS Study Group (2001) Computed tomography assessment of positive end-expiratory pressure-induced alveolar recruitment in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 163:1444–1450
  13. Gattinoni L, Caironi P, Cressoni M, Chiumello D, Ranieri VM, Quintel M, Russo S, Patroniti N, Cornejo R, Bugedo G (2006) Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med 354:1775–1786
    • View reference on PubMed
    • View reference on publisher's website
  14. Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, Legall JR, Morris A, Spragg R, The Consensus Committee (1994) The American–European consensus conference on ARDS. Definition, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 149:818–824
    • View reference on PubMed
  15. Murray JF, Matthay MA, Luce JM, Flick MR (1988) An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis 138:720–723
    • View reference on PubMed
  16. The Acute Respiratory Distress Syndrome Network (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301–1308
  17. Mentzelopoulos SD, Roussos C, Zakynthinos SG (2005) Prone position reduces lung stress and strain in severe ARDS. Eur Respir J 25:534–544
    • View reference on PubMed
    • View reference on publisher's website
  18. Goldman LW (2007) Principles of CT and CT technology. J Nucl Med Technol 35:115–128
    • View reference on PubMed
    • View reference on publisher's website
  19. Goldman LW (2008) Principles of CT: multislice CT. J Nucl Med Technol 36:57–68
    • View reference on PubMed
    • View reference on publisher's website
  20. Pelosi P, Goldner M, McKibben A, Adams A, Eccher G, Caironi P, Lossapio S, Gattinoni L, Marini JJ (2001) Recruitment and derecruitment during acute respiratory failure. An experimental study. Am J Respir Crit Care Med 164:122–130
    • View reference on PubMed
  21. Crotti S, Mascheroni D, Caironi P, Pelosi P, Ronzoni G, Mondino M, Marini JJ, Gattinoni L (2001) Recruitment and derecruitment during acute respiratory failure. A clinical study. Am J Respir Crit Care Med 164:131–140
    • View reference on PubMed
  22. Puybasset L, Gusman P, Muller JC, Cluzel P, Coriat P, Rouby JJ, CT Scan ARDS Study Group (2000) Regional distribution of gas and tissue in acute respiratory distress syndrome. III. Consequences for the effects of positive end-expiratory pressure. Intensive Care Med 26:1215–1227
  23. Puybasset L, Cluzel P, Gusman P, Grenier P, Preteux F, Rouby JJ, CT Scan ARDS Study Group (2000) Regional distribution of gas and tissue in acute respiratory distress syndrome. I. Consequences for lung morphology. Intensive Care Med 26:857–869
  24. Luecke T, Meinhardt JP, Herrmann P, Weisser G, Pelosi P, Quintel M (2003) Setting mean airway pressure during high-frequency oscillatory ventilation according to the static pressure–volume curve in surfactant-deficient lung injury. A computed tomography study. Anesthesiology 99:1313–1322
    • View reference on PubMed
    • View reference on publisher's website
  25. Derdak S, Mehta S, Stewart TE, Smith T, Rogers M, Buchman TG, Carlin B, Lowson S, Granton J, Multicenter oscillatory ventilation for acute respiratory distress syndrome trial (MOAT) study investigators (2002) High-frequency oscillatory ventilation for acute respiratory distress syndrome in adults: a randomized, controlled trial. Am J Respir Crit Care Med 166:801–808
    • View reference on PubMed
    • View reference on publisher's website
  26. Frantz ID 3rd, Close RH (1985) Alveolar pressure swings during high frequency ventilation in rabbits. Pediatr Res 19:162–166
    • View reference on PubMed
    • View reference on publisher's website
  27. Ferguson ND, Chiche JD, Kacmarek RM, Hallett DC, Mehta S, Findlay GP, Granton JT, Slutsky AS, Stewart TE (2005) Combining high-frequency oscillatory ventilation and recruitment in adults with early acute respiratory distress syndrome: the treatment with oscillation and an open lung strategy (TOOLS) trial pilot study. Crit Care Med 33:479–486
    • View reference on PubMed
    • View reference on publisher's website
  28. Funk DJ, Lujan E, Moretti EW, Davies J, Young CC, Patel MB, Vaslef SN (2008) A brief report: the use of high-frequency oscillatory ventilation for severe pulmonary contusion. J Trauma 65:390–395
    • View reference on PubMed
    • View reference on publisher's website
  29. Gattinoni L, Carlesso E, Cadringher P, Valenza F, Vagginelli F, Chiumello D (2003) Physical and biological triggers of ventilator-induced lung injury and its prevention. Eur Respir J 22(Suppl 47):15s–25s
    • View reference on publisher's website
  30. Vieira SR, Nieszkowska A, Lu Q, Elman M, Sartorius A, Rouby JJ (2005) Low spatial resolution computed tomography underestimates lung overinflation resulting from positive pressure ventilation. Crit Care Med 33:741–749
    • View reference on PubMed
    • View reference on publisher's website
  31. Reske AW, Busse H, Amato MB, Jaekel M, Kahn T, Schwarzkopf P, Schreiter D, Gottschaldt U, Seiwerts M (2008) Image reconstruction affects computer tomographic assessment of lung hyperinflation. Intensive Care Med 34:2044–2053
  32. Vieira SR, Puybasset L, Lu Q, Richecoeur J, Cluzel P, Coriat P, Rouby JJ (1999) A scanographic assessment of pulmonary morphology in acute lung injury. Significance of the lower inflection point detected on the lung pressure–volume curve. Am J Respir Crit Care Med 159:1612–1623
    • View reference on PubMed
  33. Borges JB, Okamoto VN, Matos GF, Caramez MP, Arantes PR, Barros F, Souza CE, Victorino JA, Kacmarek RM, Barbas CS, Carvalho CR, Amato MB (2006) Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome. Am J Respir Crit Care Med 174:268–278
    • View reference on PubMed
    • View reference on publisher's website
  34. Reske AW, Reske AP, Gast HA, Seiwerts M, Beda A, Gottschaldt U, Josten C, Schreiter D, Heller N, Wrigge H, Amato MB (2010) Extrapolation from ten sections can make CT-based quantification of lung aeration more practicable. Intensive Care Med 36:1836–1844
  35. Malachias S, Kokkoris S, Zakynthinos S, Mentzelopoulos SD (2009) High frequency oscillation and tracheal gas insufflation for severe acute respiratory distress syndrome: results from a single-center, phase II, randomized controlled trial [NCT00416260] [abstract]. Intensive Care Med 35(Suppl 1):S6
  36. Pillow JJ (2005) High-frequency oscillatory ventilation: mechanisms of gas exchange and lung mechanics. Crit Care Med 33(Suppl):S135–S141
    • View reference on PubMed
    • View reference on publisher's website

Sign In

Connect with ICM

Top 5 Articles Editors Picks Supplement