The impact of fluid status and decremental PEEP strategy on cardiac function and lung and kidney damage in mild-moderate experimental acute respiratory distress syndrome

Nazareth N Rocha,John J Marini,Pedro L Silva,Cynthia S Samary,Fernanda F Cruz,Milena V Oliveira,Vera L Capelozzi,Matheus R Hemerly,Mariana A Antunes,Patricia R M Rocco,Patrine S Santos,Paolo Pelosi

doi:10.1186/s12931-021-01811-y

Abstract

BackgroundWe evaluated the effects of abrupt versus gradual PEEP decrease, combined with standard versus high-volume fluid administration, on cardiac function, as well as lung and kidney damage in an established model of mild-moderate acute respiratory distress syndrome (ARDS).MethodsWistar rats received endotoxin intratracheally. After 24 h, they were treated with Ringer’s lactate at standard (10 mL/kg/h) or high (30 mL/kg/h) dose. For 30 min, all animals were mechanically ventilated with tidal volume = 6 mL/kg and PEEP = 9 cmH2O (to keep alveoli open), then randomized to undergo abrupt or gradual (0.2 cmH2O/min for 30 min) PEEP decrease from 9 to 3 cmH2O. Animals were then further ventilated for 10 min at PEEP = 3 cmH2O, euthanized, and their lungs and kidneys removed for molecular biology analysis.ResultsAt the end of the experiment, left and right ventricular end-diastolic areas were greater in animals treated with high compared to standard fluid administration, regardless of PEEP decrease rate. However, pulmonary arterial pressure, indicated by the pulmonary acceleration time (PAT)/pulmonary ejection time (PET) ratio, was higher in abrupt compared to gradual PEEP decrease, independent of fluid status. Animals treated with high fluids and abrupt PEEP decrease exhibited greater diffuse alveolar damage and higher expression of interleukin-6 (a pro-inflammatory marker) and vascular endothelial growth factor (a marker of endothelial cell damage) compared to the other groups. The combination of standard fluid administration and gradual PEEP decrease increased zonula occludens-1 expression, suggesting epithelial cell preservation. Expression of club cell-16 protein, an alveolar epithelial cell damage marker, was higher in abrupt compared to gradual PEEP decrease groups, regardless of fluid status. Acute kidney injury score and gene expression of kidney injury molecule-1 were higher in the high versus standard fluid administration groups, regardless of PEEP decrease rate.ConclusionIn the ARDS model used herein, decreasing PEEP abruptly increased pulmonary arterial hypertension, independent of fluid status. The combination of abrupt PEEP decrease and high fluid administration led to greater lung and kidney damage. This information adds to the growing body of evidence that supports gradual transitioning of ventilatory patterns and warrants directing additional investigative effort into vascular and deflation issues that impact lung protection.

Highlights

We evaluated the effects of abrupt versus gradual Positive end expiratory pressure (PEEP) decrease, combined with standard versus high-volume fluid administration, on cardiac function, as well as lung and kidney damage in an established model of mild-moderate acute respiratory distress syndrome (ARDS)
At FINAL, the mean volumes of fluids injected were 6.9 ± 2.5 mL in the group treated with standard fluid administration (NORMO) with abrupt PEEP decrease (FAST), 16.1 ± 7.2 mL in the high fluid administration (HIGH) with abrupt PEEP decrease group, 6.0 ± 1.5 mL in the standard fluid administration with gradual PEEP decrease (SLOW) group, and 15.4 ± 1.9 mL in high fluid administration with gradual PEEP decrease group
At FINAL, high fluid administration resulted in increased left ventricular (LV) and right ventricular (RV) areas, as well as right ventricular cardiac output (RVCO), regardless of velocity of PEEP decrease (Table 1)

Summary

Introduction

We evaluated the effects of abrupt versus gradual PEEP decrease, combined with standard versus high-volume fluid administration, on cardiac function, as well as lung and kidney damage in an established model of mild-moderate acute respiratory distress syndrome (ARDS). Data gathered in recent years from small-animal models with previously healthy lungs demonstrate the adverse influence of abruptly releasing high levels of PEEP [11]. This observation has been attributed primarily to cardiovascular compromise owing to the initial “surge” of translocating fluid volumes from peripheral to central vascular compartments. In experimental acute respiratory distress syndrome (ARDS); alveoli have different time constants and lung tissue sensitivity to vascular volume and flows, due to atelectasis and edema. The lung may be influenced by deflation kinetics, and by the pace of PEEP release

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