The effect of changing end-expiratory pressure on respiratory system mechanics in open- and closed-chest...

The decrease in functional residual capacity (FRC) with anesthesia may cause lung volume to decrease below closing volume, thereby impairing oxygenation. Increasing end-expiratory pressure (EEP) reexpands atelectatic areas in anesthetized, ventilated patients, but its effect on pulmonary mechanics is less well understood. We studied the effect of varying EEP on the mechanical behavior of the respiratory system in patients undergoing either closed (Group 1) or open-chest (Group 2) surgical procedures. We measured airway opening pressure (PaO), flow (V), and esophageal pressure (Pes) (in Group 1 only) at EEPs of 0, 2.5, 5, and 10 cm H2O. Dynamic elastance (E) and resistance (R) for the respiratory system (RS), the lung (L), and the chest wall (CW) were estimated by fitting the equation P = RV + EV + K to the measured data by multiple linear regression where P was either Pao, Pes, or Pao-Pes. Group 1 EL decreased with increases in EEP to 5 cm H2O and then began to increase with EEP above this level. The same occurred in Group 2 before opening the chest. After opening the chest in Group 2, EL increased as EEP increased at all values above 0 cm H2O. The magnitudes of RRS and RL were similar in both groups of subjects and in each group these quantities decreased with increases in EEP. Dynamic EL responded differently to changes in EEP in subjects with open-chest and closed-chest procedures. We attribute this difference to overdistension of the remaining ventilable lung tissue at all levels of EEP in open-chest patients.