Transpulmonary Pressure Describes Lung Morphology During Decremental Positive End-Expiratory Pressure Trials in Obesity

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dc.contributorSistema FMUSP-HC: Faculdade de Medicina da Universidade de São Paulo (FMUSP) e Hospital das Clínicas da FMUSP
dc.contributor.authorFUMAGALLI, Jacopo
dc.contributor.authorBERRA, Lorenzo
dc.contributor.authorZHANG, Changsheng
dc.contributor.authorPIRRONE, Massimiliano
dc.contributor.authorSANTIAGO, Roberta R. De Santis
dc.contributor.authorGOMES, Susimeire
dc.contributor.authorMAGNI, Federico
dc.contributor.authorSANTOS, Glaucia A. B. dos
dc.contributor.authorBENNETT, Desmond
dc.contributor.authorTORSANI, Vinicius
dc.contributor.authorFISHER, Daniel
dc.contributor.authorMORAIS, Caio
dc.contributor.authorAMATO, Marcelo B. P.
dc.contributor.authorKACMAREK, Robert M.
dc.date.accessioned2017-08-17T19:15:14Z
dc.date.available2017-08-17T19:15:14Z
dc.date.issued2017
dc.description.abstractObjectives: Atelectasis develops in critically ill obese patients when undergoing mechanical ventilation due to increased pleural pressure. The current study aimed to determine the relationship between transpulmonary pressure, lung mechanics, and lung morphology and to quantify the benefits of a decremental positive end-expiratory pressure trial preceded by a recruitment maneuver. Design: Prospective, crossover, nonrandomized interventional study. Setting: Medical and Surgical Intensive Care Units at Massachusetts General Hospital (Boston, MA) and University Animal Research Laboratory (Sao Paulo, Brazil). Patients/Subjects: Critically ill obese patients with acute respiratory failure and anesthetized swine. Interventions: Clinical data from 16 mechanically ventilated critically ill obese patients were analyzed. An animal model of obesity with reversible atelectasis was developed by placing fluid filled bags on the abdomen to describe changes of lung mechanics, lung morphology, and pulmonary hemodynamics in 10 swine. Measurements and Main Results: In obese patients (body mass index, 48 +/- 11 kg/m(2)), 21.7 +/- 3.7 cm H2O of positive end-expiratory pressure resulted in the lowest elastance of the respiratory system (18.6 +/- 6.1 cm H2O/L) after a recruitment maneuver and decremental positive end-expiratory pressure and corresponded to a positive (2.1 +/- 2.2 cm H2O) end-expiratory transpulmonary pressure. Ventilation at lowest elastance positive end-expiratory pressure preceded by a recruitment maneuver restored end-expiratory lung volume (30.4 +/- 9.1 mL/kg ideal body weight) and oxygenation (273.4 +/- 72.1 mm Hg). In the swine model, lung collapse and intratidal recruitment/derecruitment occurred when the positive end-expiratory transpulmonary pressure decreased below 2-4 cm H2O. After the development of atelectasis, a decremental positive end-expiratory pressure trial preceded by lung recruitment identified the positive end-expiratory pressure level (17.4 +/- 2.1 cm H2O) needed to restore poorly and nonaerated lung tissue, reestablishing lung elastance and oxygenation while avoiding increased pulmonary vascular resistance. Conclusions: In obesity, low-to-negative values of transpulmonary pressure predict lung collapse and intratidal recruitment/derecruitment. A decremental positive end-expiratory pressure trial preceded by a recruitment maneuver reverses atelectasis, improves lung mechanics, distribution of ventilation and oxygenation, and does not increase pulmonary vascular resistance.
dc.description.indexMEDLINE
dc.description.sponsorshipTimpel S.A.
dc.description.sponsorshipCovidien
dc.description.sponsorshipTeleflex
dc.description.sponsorshipOrange Medical
dc.description.sponsorshipDepartment of Anesthesia, Critical Care and Pain Medicine
dc.description.sponsorshipRespiratory Care Services Massachusetts General Hospital
dc.description.sponsorshipFoundation for Anesthesia Education and Research
dc.description.sponsorshipFundacao de Amparo e Pesquisa do Estado de Sao Paulo, Brazil
dc.description.sponsorshipFinanciadora de Estudos e Projetos, Brazil
dc.identifier.citationCRITICAL CARE MEDICINE, v.45, n.8, p.1374-1381, 2017
dc.identifier.doi10.1097/CCM.0000000000002460
dc.identifier.eissn1530-0293
dc.identifier.issn0090-3493
dc.identifier.urihttps://observatorio.fm.usp.br/handle/OPI/21261
dc.language.isoeng
dc.publisherLIPPINCOTT WILLIAMS & WILKINS
dc.relation.ispartofCritical Care Medicine
dc.rightsrestrictedAccess
dc.rights.holderCopyright LIPPINCOTT WILLIAMS & WILKINS
dc.subjectelectrical impedance tomography
dc.subjectlung CT scan
dc.subjectlung recruitment
dc.subjectpositive end-expiratory pressure
dc.subjecttranspulmonary pressure
dc.subject.otherelectrical-impedance tomography
dc.subject.otherrespiratory-distress-syndrome
dc.subject.othermechanical ventilation
dc.subject.othercollapse
dc.subject.otherinjury
dc.subject.otheratelectasis
dc.subject.otherrecruitment
dc.subject.otheranesthesia
dc.subject.othertitration
dc.subject.otherfailure
dc.subject.wosCritical Care Medicine
dc.titleTranspulmonary Pressure Describes Lung Morphology During Decremental Positive End-Expiratory Pressure Trials in Obesity
dc.typearticle
dc.type.categoryoriginal article
dc.type.versionpublishedVersion
dspace.entity.typePublication
hcfmusp.affiliation.countryItália
hcfmusp.affiliation.countryEstados Unidos
hcfmusp.affiliation.countryisoit
hcfmusp.affiliation.countryisous
hcfmusp.author.externalFUMAGALLI, Jacopo:Massachusetts Gen Hosp, Dept Anesthesia Crit Care & Pain Med, Boston, MA 02114 USA; Univ Milan, Dipartimento Fisiopatol Med Chirurg & Trapianti, Milan, Italy
hcfmusp.author.externalBERRA, Lorenzo:Massachusetts Gen Hosp, Dept Anesthesia Crit Care & Pain Med, Boston, MA 02114 USA
hcfmusp.author.externalZHANG, Changsheng:Massachusetts Gen Hosp, Dept Anesthesia Crit Care & Pain Med, Boston, MA 02114 USA
hcfmusp.author.externalPIRRONE, Massimiliano:Massachusetts Gen Hosp, Dept Anesthesia Crit Care & Pain Med, Boston, MA 02114 USA; Univ Milan, Dipartimento Fisiopatol Med Chirurg & Trapianti, Milan, Italy
hcfmusp.author.externalMAGNI, Federico:Univ Milano Bicocca, Dipartimento Med & Chirurgia, Milan, Italy
hcfmusp.author.externalBENNETT, Desmond:Massachusetts Gen Hosp, Resp Care Dept, Boston, MA 02114 USA
hcfmusp.author.externalFISHER, Daniel:Massachusetts Gen Hosp, Resp Care Dept, Boston, MA 02114 USA
hcfmusp.author.externalKACMAREK, Robert M.:Massachusetts Gen Hosp, Resp Care Dept, Boston, MA 02114 USA
hcfmusp.citation.scopus79
hcfmusp.contributor.author-fmusphcROBERTA RIBEIRO DE SANTIS SANTIAGO
hcfmusp.contributor.author-fmusphcSUSIMEIRE GOMES
hcfmusp.contributor.author-fmusphcGLAUCIA APARECIDA BENTO DOS SANTOS
hcfmusp.contributor.author-fmusphcVINICIUS TORSANI
hcfmusp.contributor.author-fmusphcCAIO CESAR ARAUJO MORAIS
hcfmusp.contributor.author-fmusphcMARCELO BRITTO PASSOS AMATO
hcfmusp.description.beginpage1374
hcfmusp.description.endpage1381
hcfmusp.description.issue8
hcfmusp.description.volume45
hcfmusp.origemWOS
hcfmusp.origem.pubmed28708679
hcfmusp.origem.scopus2-s2.0-85017597470
hcfmusp.origem.wosWOS:000405469600037
hcfmusp.publisher.cityPHILADELPHIA
hcfmusp.publisher.countryUSA
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