Intratracheal Pulmonary Ventilation at Low Airway Pressures in a Ventilator-Induced Model of Acute Respiratory Failure Improves Lung Function and Survival
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STUDY OBJECTIVE: The pulmonary parenchyma in patients with acute respiratory failure (ARF) is commonly not involved in a homogenous disease process. Conventional mechanical ventilation (MV) at elevated positive end-expiratory pressure (PEEP) and peak inspiratory pressure (PIP) aims at recruiting collapsed or nonventilated lung units. Invariably, those pressures are also transmitted to the healthiest regions, with possible extension of the disease process (barotrauma). During intratracheal pulmonary ventilation (ITPV), a continuous flow of fresh gas is delivered directly at the carina, bypassing the dead space proximal to the catheter tip. In healthy sheep, it allows lowering tidal volume (VT) to as low as 1.0 mL/kg, at respiratory rates (RR) up to 120 breaths/min, while maintaining normocapnia. In a model of ventilator-induced lung injury, we wished to explore whether ITPV, applied at low VT and low PEEP and tailored to ventilate the healthiest regions of the lungs, could provide adequate oxygenation and alveolar ventilation, without any attempt to recruit lungs. DESIGN: Randomized study in sheep. SETTING: Animal research laboratory. PARTICIPANTS: We induced ARF in 12 sheep following 1 to 2 days of MV at a PIP of 50 cm H2O, except that 5 to 8% of lungs were kept on apneic oxygenation of 5 cm H2O, sparing those regions from the injury process. INTERVENTIONS: Sheep were randomized to volume-controlled MV (control group) (n = 6) with VT of 8 to 12 mL/kg, PEEP of 5 to 10 cm H2O, or to ITPV (n = 6) at PEEP of 3 to 5 cm H2O, VT of 2.5 to 4 mL/kg, PIP of <20 cm H2O, at RRs sufficient to sustain normocapnia. MEASUREMENTS AND RESULTS: Hemodynamic status in the ITPV group progressively improved, and all six sheep were weaned to room air within 83+/-54 h. Sheep in the control group had progressively deteriorating conditions and all animals died after a mean of 50+/-39 h. Barotrauma and postmortem histopathologic changes were more pronounced in the control group. CONCLUSION: In this model of ventilator-induced lung injury, low PEEP-low VT ventilation with ITPV sustained normocapnia and prevented further lung injury, allowing weaning to room air ventilation.
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