Effects of pressure support and pressure-controlled ventilation on lung damage in a model of mild extrapulmonary acute lung injury with intra-abdominal hypertension.

Cintia L Santos,Johnatas D Silva,Marcelo G Abreu,Alberto Schanaider,Robert Huhle,Cynthia S Samary,Pedro L Silva,Patricia R M Rocco,Lillian Moraes,Marcelo M Morales,Raquel S Santos,Nathane S Felix,Paolo Pelosi,Nades Palaniyar

doi:10.1371/journal.pone.0178207

Abstract

Intra-abdominal hypertension (IAH) may co-occur with the acute respiratory distress syndrome (ARDS), with significant impact on morbidity and mortality. Lung-protective controlled mechanical ventilation with low tidal volume and positive end-expiratory pressure (PEEP) has been recommended in ARDS. However, mechanical ventilation with spontaneous breathing activity may be beneficial to lung function and reduce lung damage in mild ARDS. We hypothesized that preserving spontaneous breathing activity during pressure support ventilation (PSV) would improve respiratory function and minimize ventilator-induced lung injury (VILI) compared to pressure-controlled ventilation (PCV) in mild extrapulmonary acute lung injury (ALI) with IAH. Thirty Wistar rats (334±55g) received Escherichia coli lipopolysaccharide intraperitoneally (1000μg) to induce mild extrapulmonary ALI. After 24h, animals were anesthetized and randomized to receive PCV or PSV. They were then further randomized into subgroups without or with IAH (15 mmHg) and ventilated with PCV or PSV (PEEP = 5cmH2O, driving pressure adjusted to achieve tidal volume = 6mL/kg) for 1h. Six of the 30 rats were used for molecular biology analysis and were not mechanically ventilated. The main outcome was the effect of PCV versus PSV on mRNA expression of interleukin (IL)-6 in lung tissue. Regardless of whether IAH was present, PSV resulted in lower mean airway pressure (with no differences in peak airway or peak and mean transpulmonary pressures) and less mRNA expression of biomarkers associated with lung inflammation (IL-6) and fibrogenesis (type III procollagen) than PCV. In the presence of IAH, PSV improved oxygenation; decreased alveolar collapse, interstitial edema, and diffuse alveolar damage; and increased expression of surfactant protein B as compared to PCV. In this experimental model of mild extrapulmonary ALI associated with IAH, PSV compared to PCV improved lung function and morphology and reduced type 2 epithelial cell damage.

Highlights

Intra-abdominal hypertension (IAH) is a clinical condition characterized by intra-abdominal pressure (IAP) ! 12 mmHg
mean arterial pressure (MAP) was maintained above 60 mmHg throughout the experiments (Additional file 2: S2 Table)
At Start, MAP was higher in pressure support ventilation (PSV) than pressure-controlled ventilation (PCV), regardless of normal intra-abdominal pressure (nIAP) or IAH

Summary

Introduction

Intra-abdominal hypertension (IAH) is a clinical condition characterized by intra-abdominal pressure (IAP) ! 12 mmHg. Intra-abdominal hypertension (IAH) is a clinical condition characterized by intra-abdominal pressure (IAP) ! 12 mmHg. Intra-abdominal hypertension (IAH) is a clinical condition characterized by intra-abdominal pressure (IAP) ! In the presence of preexisting alveolar-capillary damage, IAH promotes lung injury [6,7,8], edema, and increased intra-thoracic pressures, leading to atelectasis, airway closure, and deterioration of gas exchange [6]. Controlled mechanical ventilation with low tidal volume and optimization of positive end-expiratory pressure (PEEP), combined with neuromuscular blockade, has been recommended as a strategy to minimize ventilator-induced lung injury (VILI) [4,9]. IAH has been shown to potentiate dorsal atelectasis formation [6], and the relaxation of the respiratory muscles during controlled mechanical ventilation allows further cephalad displacement of the diaphragm, predominately in the ventral regions

Methods

Discussion

Conclusion