Effects of thoracotomy on respiratory system, lung, and chest wall mechanics

Asymmetrical Lung Injury: Management and Outcome

Among mechanically ventilated patients, asymmetrical lung injury is probably extremely frequent in the intensive care unit but the lack of standardized measurements does not allow to describe any prevalence among mechanically ventilated patients. Many past studies have focused only on unilateral injury and have mostly described the effect of lateral positioning. The good lung put downward might receive more perfusion while the sick lung placed upward receive more ventilation than supine. This usually results in better oxygenation but can also promote atelectasis in the healthy lung and no consensus has emerged on the clinical indication of this posture. Recently, electrical impedance tomography (EIT) has allowed for the first time to precisely describe the distribution of ventilation in each lung and to better study asymmetrical lung injury. At low positive-end-expiratory pressure (PEEP), a very heterogeneous ventilation exists between the two lungs and the initial increase in PEEP first helps to recruit the sick lung and protect the healthier lung. However, further increasing PEEP distends the less injured lung and must be avoided. The right level can be found using EIT and transpulmonary pressure. In addition, EIT can show that in the two lungs, airway closure is present but with very different airway opening pressures (AOPs) which cannot be identified on a global assessment. This may suggest a very different PEEP level than on a global assessment. Lastly, epidemiological studies suggest that in hypoxemic patients, the number of quadrants involved has a strong prognostic value. The number of quadrants is more important than the location of the unilateral or bilateral nature of the involvement for the prognosis, and hypoxemic patients with unilateral lung injury should probably be considered as requiring lung protective ventilation as classical acute respiratory distress syndrome.

Cardiovascular and Gas Exchange Effects of Individualized Positive End-Expiratory Pressures in Cats Anesthetized With Isoflurane

Objectives

To compare the effects of four levels of end-expiratory pressure [zero (ZEEP) and three levels of positive end-expiratory pressure (PEEP)] on the cardiovascular system and gas exchange of cats anesthetized with isoflurane and mechanically ventilated for 3 h with a tidal volume of 10 ml/kg.

Study Design

Prospective, randomized, controlled trial.

Animals

Six healthy male neutered purpose-bred cats.

Methods

Anesthesia was induced with isoflurane and maintained at 1.3 minimum alveolar concentration. PEEP of maximal respiratory compliance (PEEP_maxCrs) was identified in a decremental PEEP titration, and cats were randomly ventilated for 3 h with one of the following end-expiratory pressures: ZEEP, PEEP_maxCrs minus 2 cmH₂O (PEEP_maxCrs−2), PEEP_maxCrs, and PEEP_maxCrs plus 2 cmH₂O (PEEP_maxCrs+2). Cardiovascular and gas exchange variables were recorded at 5, 30, 60, 120, and 180 min (T5 to T180, respectively) of ventilation and compared between and within ventilation treatments with mixed-model ANOVA followed by Dunnet's and Tukey's tests (normal distribution) or Friedman test followed by the Dunn's test (non-normal distribution). Significance to reject the null hypothesis was considered p < 0.05.

Results

Mean arterial pressure (MAP—mmHg) was lower in PEEP_maxCrs+2 [63 (49–69); median (range)] when compared to ZEEP [71 (67–113)] at T5 and stroke index (ml/beat/kg) was lower in PEEP_maxCrs+2 (0.70 ± 0.20; mean ± SD) than in ZEEP (0.90 ± 0.20) at T60. Cardiac index, oxygen delivery index (DO₂I), systemic vascular resistance index, and shunt fraction were not significantly different between treatments. The ratio between arterial partial pressure and inspired concentration of oxygen (PaO₂/FIO₂) was lower in ZEEP than in the PEEP treatments at various time points. At T180, DO₂I was higher when compared to T5 in PEEP_maxCrs. Dopamine was required to maintain MAP higher than 60 mmHg in one cat during PEEP_maxCrs and in three cats during PEEP_maxCrs+2.

Conclusion

In cats anesthetized with isoflurane and mechanically ventilated for 3 h, all levels of PEEP mildly improved gas exchange with no significant difference in DO₂I when compared to ZEEP. The PEEP levels higher than PEEP_maxCrs−2 caused more cardiovascular depression, and dopamine was an effective treatment. A temporal increase in DO₂I was observed in the cats ventilated with PEEP_maxCrs. The effects of these levels of PEEP on respiratory mechanics, ventilation-induced lung injury, as well as in obese and critically ill cats deserve future investigation for a better understanding of the clinical use of PEEP in this species.

Hypertension and vulnerability to hemorrhagic shock in a rat model

Trauma mortality may be increased in the presence of preexisting diseases such as chronic hypertension. We hypothesized that systemic and microvascular alterations accompanying chronic hypertension would increase the vulnerability to hemorrhage relative to normotensive controls in a rat model of hemorrhagic shock. We present a novel comparative hemorrhage model of shock vulnerability, quantified by "vulnerability curves" expressing physiological response to hemorrhage as a function of three matched shock metrics: cumulative blood volume, mean arterial pressure (MAP), and oxygen delivery (Do2). Responses were central hemodynamics and respiratory and muscle oxygenation obtained for one hypertensive (spontaneously hypertensive [SHR]) and two normotensive (Sprague-Dawley, Wistar-Kyoto) rat strains. Hemorrhagic shock was induced by incremental (0.5 mL) hemorrhage to cardiovascular collapse in anesthetized and mechanically ventilated animals. Shock vulnerability of SHR rats was primarily pressure-driven; in general, SHR exhibited the expected patterns of more rapid deterioration in MAP and Vo2 over smaller ranges of blood loss and Do2. Sternotomy-related depression of CO and thus Do2 in SHR meant that we could not test hypotheses related to the role of Do2 and contribution to perfusion differences between normotensive and hypertensive subjects. Insensitivity of lactate to strain effects suggests that lactate may be a reliable biomarker of shock status. Unexpected similarities between Wistar-Kyoto and SHR suggest strain-related effects other than those related to hypertension per se contribute to hemorrhage response; body size effects and genetic relationships could not be ruled out. Future studies should incorporate phylogenetically based methods to examine the role of hypertension and physiological response to hemorrhage across multiple strains.

Evaluation of respiratory mechanics and lung histology in a model of atelectasis

To develop a reproducible model of atelectasis, 15 mechanically ventilated Wistar rats were wrapped around the thorax/abdomen with a sphygmomanometer. The cuff was inflated to transpulmonary pressures (PL) of -4 cmH2O (group A) and -8 cmH2O (group B) for 5 sec. Group C was not compressed. Airflow, volume, tracheal and oesophageal pressures were registered. Respiratory system (rs), lung (L), and chest wall resistive (DeltaP1), viscoelastic/inhomogeneous pressures (DeltaP2), DeltaPtot (=DeltaP1 + DeltaP2), static (Est) and dynamic (Edyn) elastances, and DeltaE (=Edyn - Est) were determined before and after compression. In A, respiratory mechanics remained unaltered. In B, Est,rs (+99%), Est,L (+111%), DeltaE,rs (+41%), DeltaE,L (+73%), DeltaP1,rs (+45%), DeltaP1,L (+44%), DeltaP2,rs (+41%), DeltaP2,L (+69%), DeltaPtot,rs (+40%), and DeltaPtot,L (+58%) increased after compression. Mean alveolar diameter and bronchiolar lumen decreased in A, and were even smaller in B. In conclusion, chest wall compression with PL of -8 cmH2O yielded a reproducible alveolar collapse, which resulted in increased elastic, resistive and viscoelastic/inhomogeneous pressures.

Respiratory mechanics after prosthetic reconstruction of the chest wall in normal rats

OBJECTIVE

Prosthetic reconstruction of the chest wall may yield several respiratory changes. Nevertheless, to our knowledge, no comprehensive analysis of respiratory mechanics under this condition has been hitherto performed.

METHODS

Respiratory mechanics were evaluated in two groups of rats. In one group (n=8), a polytetrafluoroethylene (PTFE) patch was used; in another group (n=8), a polypropylene mesh (Marlex) associated with methylmethacrylate (PPMM) was employed. All animals were sedated, anesthetized, paralyzed, and mechanically ventilated before and after the prosthetic reconstruction of the chest wall. After airway occlusion at end inspiration, respiratory system, pulmonary, and chest wall resistive pressures (deltaP1rs, deltaP1L, and deltaP1cw, respectively) and viscoelastic/inhomogeneous pressures (deltaP2rs, deltaP2L, and deltaP2cw, respectively) were determined. Respiratory system, lung, and chest wall static (Est(rs), EstL, and Est(cw), respectively), and dynamic elastances (Edyn(rs), EdynL, and Edyn(cw), respectively), and the corresponding delta elastances (deltaE, calculated as Edyn-Est) were also obtained.

RESULTS

In both groups, significant increases in deltaP2rs, deltaP2cw, deltaErs, deltaEcw, Est(rs), EstL, and Est(cw) were observed after chest wall reconstruction. However, deltaP2rs, deltaP2cw, deltaErs, deltaEcw, Est(rs), and EstL were significantly higher in the PPMM group than in the PTFE group.

CONCLUSIONS

Prosthetic reconstruction of the chest wall yields not only elastic changes, but also there is also an important increase of pressure dissipated against viscoelastic/inhomogeneous segments of the chest wall. Furthermore, taking into account respiratory mechanics, the PTFE patch might be preferred to the PPMM patch.