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Set positive end-expiratory pressure during protective ventilation affects lung injury
Muneyuki Takeuchi1, Sven Goddon, Marisa Dolhnikoff
1Department of Anesthesia/Respiratory Care, Massachusetts General Hospital, The Center for Blood Research, Boston 02114, USA.
Background:
The most appropriate method of determining positive end-expiratory pressure (PEEP) level during a lung protective ventilatory strategy has not been established.
Methods:
In a lavage-injured sheep acute respiratory distress syndrome model, the authors compared the effects of three approaches to determining PEEP level after a recruitment maneuver: (1) 2 cm H(2)O above the lower inflection point on the inflation pressure-volume curve, (2) at the point of maximum curvature on the deflation pressure-volume curve, and (3) at the PEEP level that maintained target arterial oxygen partial pressure at a fraction of inspired oxygen of 0.5.
Results:
Positive end-expiratory pressure set 2 cm H(2)O above the lower inflection point resulted in the least injury over the course of the study. PEEP based on adequate arterial oxygen partial pressure/fraction of inspired oxygen ratios had to be increased over time and resulted in higher mRNA levels for interleukin-8 and interleukin-1beta and greater tissue inflammation when compared with the other approaches. PEEP at the point of maximum curvature could not maintain eucapneia even at an increased ventilatory rate.
Conclusion:
Although generating higher plateau pressures, PEEP levels based on pressure-volume curve analysis were more effective in maintaining gas exchange and minimizing injury than PEEP based on adequate oxygenation. PEEP at 2 cm H(2)O above the lower inflection point was most effective.