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Table of Contents
ORIGINAL ARTICLE
Year : 2017  |  Volume : 6  |  Issue : 4  |  Page : 163-168

Effect of protective lung ventilation strategy combined with lung recruitment maneuver in patients with acute respiratory distress syndrome (ARDS)


1 Department of Intensive Care Unit, Changshu Second People's Hospital in Jiangsu Province, Changshu 215500, China
2 Endocrinology Department, the 117th Hospital of PLA, Hangzhou 310013, China
3 Department of Intensive Care Unit, the First Affiliated Hospital of Suzhou University, Suzhou 215006, China
4 Department of Emergency and Intensive Care Unit, Changzheng Hospital Affiliated to the Second Military Medical University, Shanghai 200003, China

Date of Web Publication20-Sep-2017

Correspondence Address:
Sheng Yu
Department of Emergency and Intensive Care Unit, Changzheng Hospital Affiliated to the Second Military Medical University, Shanghai 200003
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.12980/jad.6.20170403

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  Abstract 


Objective: To evaluate the efficacy and safety of protective lung ventilation strategy combined with lung recruitment maneuver (RM) in the treatment patients with acute respiratory distress syndrome (ARDS). Methods: Totally 74 patients with ARDS admitted to the Department of Intensive Care Unit, Changshu Second People's Hospital in Jiangsu Province between September 2010 and June 2013 were selected and randomly divided into lung recruitment group and non-lung recruitment group, and the initial ventilation solution for both groups was synchronized intermittent mandatory ventilation (SIMV). For RM, SIMV mode (pressure control and pressure support) was adopted. Positive end expiratory pressure (PEEP) was increased by 5 cm H2O every time and maintained for 40-50 s before entering the next increasing period, and the peak airway pressure was kept below 45 cm H2O. After PEEP reached the maximum value, it was gradually reduced by 5 cm H2O every time and finally maintained at 15 cm H2O for 10 min. Results: A total of 74 patients with mean age of (49.0±18.6) years old were enrolled, 36 patients were enrolled in lung recruitment maneuver (RM) group and 38 patients were enrolled into non-lung recruitment maneuver (non-RM) group. 44 were male and accounted for 59.5% of all the patients. For the indicators such as PEEP, pressure support (PS), plateau airway pressure (Pplat), peak airway pressure (Ppeak), vital capacity (VC) and fraction of inspired oxygen (FiO2), no statistical differences in the indicators were found between the RM group and non-RM group on D1, D3 and D7 (P>0.05), except that only FiO2 of RM group on D7 was significantly lower than that of non-RM group (47.2±10.0) vs. (52.2±10.5), P<0.05]. For the indicators of blood gas analysis, including pH, arterial oxygen pressure (PaO2), arterial carbon dioxide pressure (PaCO2) and oxygenation index (PaO2/FiO2), PaO2 and PaO2/FiO2 of RM group were significantly higher than those of non-RM group on D7, and the values were [(90.2±16.1) mmHg vs. (76.4±11.3) mmHg, P<0.05] and [(196.5±40.7) mmHg vs. (151.7±37.3) mmHg, P<0.05] respectively. There was no statistical difference in heart rate (HR), cardiac index (CI), central venous pressure (CVP) or mean arterial pressure (MAP) between RM group and non-RM group on D1, D3 and D7 (P>0.05). 28-day mortality, ICU mortality and in-hospital mortality were 25% vs. 28.9%, 25% vs. 26.3% and 36.1% vs. 39.5% respectively between RM group and non-RM group (all P>0.05). Conclusion: Protective lung ventilation strategy combined with lung recruitment maneuver can improve the indicators such as PaO2, FiO2 and PaO2/FiO2 on D7, but failed to improve the final outcomes such as 28-day mortality, ICU mortality and in-hospital mortality.

Keywords: Acute respiratory distress syndrome, Lung recruitment maneuver, Mechanical ventilation, Positive end expiratory pressure


How to cite this article:
Yu S, Hu TX, Jin J, Zhang S. Effect of protective lung ventilation strategy combined with lung recruitment maneuver in patients with acute respiratory distress syndrome (ARDS). J Acute Dis 2017;6:163-8

How to cite this URL:
Yu S, Hu TX, Jin J, Zhang S. Effect of protective lung ventilation strategy combined with lung recruitment maneuver in patients with acute respiratory distress syndrome (ARDS). J Acute Dis [serial online] 2017 [cited 2019 May 20];6:163-8. Available from: http://www.jadweb.org/text.asp?2017/6/4/163/215196




  1. Introduction Top


Acute respiratory distress syndrome (ARDS) is one of the common critical diseases in the emergency department and ICU, and mechanical ventilation is an important therapy for respiratory support in patients with ARDS[1],[2],[3]. In recent years, researches have shown that small tidal volume ventilation (6 vs. 12 mL/Kg) in protective lung ventilation strategy can significantly increase the survival rate of patients with ARDS, and its important mechanism is to reduce the shearing injury caused by persistent alveolar opening and closing[4],[5]. However, small tidal volume ventilation can also cause some bad consequences, and the most important adverse consequence is the alveolar collapse and atelectasis caused by insufficient ventilation[6],[7]. Animal experiments show that lung recruitment maneuver (RM) can reduce the alveolar collapse caused by small tidal volume ventilation strategy, and improve the oxygenation and respiratory dynamics indexes of experimental animals[8]. However, it remains controversial whether RM can improve clinical outcomes in patients with ARDS[9],[10]. Therefore, protective lung ventilation strategy combined with lung RM technique [positive end-expiratory pressure (PEEP) incremental method] was to be adopted in this research, and it was explored whether the ventilation strategy could improve the respiratory parameters, blood gas analysis indexes, hemodynamic indexes, clinical prognosis, etc., in patients with ARDS.


  2. Materials and methods Top


2.1. Research subjects

The patients with ARDS admitted to the Department of Intensive Care Unit, Changshu Second People's Hospital in Jiangsu Province between September 2010 and June 2013. The research was approved by the ethics committee of Changshu Second People's Hospital, and in line with the ethics standard of clinical research. All patients or their clients signed written informed consent.

2.2. Inclusion criteria

According to the ARDS Berlin standard[1]: with risk factors for ARDS; with acute onset, respiratory frequency and (or) respiratory distress; X ray showed two-lung patch invasion; eliminating cardiac pulmonary edema; with hypoxemia, PaO2/FiO2 ≤ 300 mmHg.

2.3. Exclusion criteria

Less than 18 years old; pregnant; the expected hospital stay less than 48 h; with end-stage chronic disease or malignant disease; with intracranial hypertension or neuromuscular disorders; patients with lobectomy; patients without spontaneous breathing.

2.4. Grouping method

Stratified randomized controlled method. The enrolled patients were first classified according to the pathogeny of ARDS, and then each type of the patients was randomly assigned to the RM or non-RM group. Random assignment was achieved by computer-generated random number, and sealed envelope was used for allocation concealment.

Clinical general data of two groups of patients are shown in [Table 1]. A total of 74 patients with ARDS were enrolled, RM group included 36 cases, non-RM group included 38 cases, and 44 patients were male and accounted for 59.5% of the total amount. The average age was (49.0±18.6) years old. The common causes of ARDS were lung infections (20 cases), sepsis or septic shock (13 cases), drowning and aspiration (9 cases), acute pancreatitis (9 cases), pulmonary contusion (8 cases), etc in turn. RM group and non-RM group were not statistically different in age, gender, APACHEII score and ARDS causes on admission (P>0.05), and the clinical data of two groups of patients were comparable.
Table 1: Clinical characteristics of RM group and non-RM group on admission.

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2.5. Mechanical ventilation

Initial ventilation solution was synchronized intermittent mandatory ventilation (SIMV), and the capacity control + pressure support or pressure control + pressure support scheme was selected. parameter settings: suitable PEEP levels were selected according to patients' condition, namely for the fraction of inspired oxygen (FiO2) less than 60%, maintaining the minimum target oxygenation PEEP level, restricted platform pressure less than 30 cm H2O and tidal volume 6–7 mL/kg[11],[12]; the target parameters: blood gas analysis pH 7.30–7.45, PaO2 60–80 mmHg or SaO2 90%–95%, PaCO2 35–55 mmHg[11],[12].

2.6. Lung RM process

Patients were fully calm before implementation of lung recruitment, and sedation reached Ramsay score 4–5 grade. Patients received pure oxygen intake for 5 min before lung RM to ensure adequate oxygenation. Respirator mode was adjusted to SIMV pressure control + pressure support, and PEEP incremental method was adopted for RM: PEEP was increased by 5 cm H2O every time from baseline and maintained for 40–50 s before entering into the next PEEP incremental period. During PEEP incremental process, in order to control the peak airway pressure below 45 cm H2O all along, PS was decreased by 5 cm H2O when PEEP was increased by 5 cm H2O after Ppeak was equal to 45 cm H2O, PEEP was gradually reduced by 5 cm H2O after reaching the peak, finally PEEP 15 cm H2O was maintained for 10 min, and then PEEP and other respiratory parameters were adjusted to the levels before lung recruitment. Lung RM flow chart is shown in [Figure 1], and each RM lasted for about 17 min and repeated every 8 h[13].
Figure 1: Lung recruitment flow chart.

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2.7. Observation indexes

The general information, respirator conditions and ARDS causes of the enrolled patients; dynamic changes of respirator parameters such as PEEP, pressure support (PS), plateau airway pressure (Pplat), peak airway pressure (Ppeak), vital capacity (VC) and fraction of inspired oxygen (FiO2) of RM group and non-RM group on D1, D3 and D7; blood gas analysis results such as pH, arterial oxygen pressure (PaO2), arterial carbon dioxide pressure (PaCO2) and oxygenation index (PaO2/FiO2) of RM group and non-RM group on D1, D3 and D7; dynamic change of hemodynamic parameters such as heart rate (HR), cardiac index (CI), central venous pressure (CVP) or mean arterial pressure (MAP) of RM group and non-RM group on D1, D3 and D7; prognostic indicators such as 28-day mortality, ICU mortality, in-hospital mortality and incidence of complications.

2.8. Statistical analysis

Normally distributed data were in terms of mean±standard deviation), and by t-test of two groups of independent samples was adopted; non-normally distributed data were in terms of median (interquartile range), and by Mann-Whitney rank sum test; count data were in terms of number (percentage), and by four-fold table λ2 test or the Fisher's exact test. Survival function analysis was by Kaplan-Meier method, and the survival function comparison between groups was by the Log-rank test. All statistical analysis was finished by SPSS 20.0. P<0.05 indicated that the difference was statistically significant.


  3. Results Top


3.1. Respirator parameters of RM group and non-RM group on D1, D3 and D7

Respirator parameters of two groups of patients on D1, D3 and D7 are shown in [Table 2]. For the indicators such as PEEP, PS, Pplat, Ppeak, VC and FiO2 of RM group and non-RM group, no statistical differences in the indicators were found between the RM group and non-RM group on D1, D3 and D7 (P>0.05), except that only FiO2 of RM group on D7 was significantly lower than that of non-RM group [(47.2±10.0) vs. (52.2±10.5), P<0.05].
Table 2: Comparison of respirator parameters between RM group and non-RM group on D1, D3 and D7.

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3.2. Blood gas analysis results of RM group and non-RM group on D1, D3 and D7

Blood gas analysis results of two groups of patients on D1, D3 and D7 are shown in [Table 3]. For the indicators of blood gas analysis, including pH, PaO2, PaCO2 and PaO2/FiO2, PaO2 and PaO2/FiO2 of RM group were significantly higher than those of non-RM group on D7 (P<0.05).
Table 3: Comparison of blood gas analysis results between RM group and non-RM group on D1, D3 and D7.

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3.3. Hemodynamic parameters of RM group and non-RM group on D1, D3 and D7

Hemodynamic parameters of two groups of patients on D1, D3 and D7 are shown in [Table 4]. There was no statistical difference in HR, CI, CVP or MAP between RM group and non-RM group on D1, D3 and D7 (P>0.05).
Table 4: Comparison of hemodynamic parameters between RM group and non-RM group on D1, D3 and D7.

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3.4. Clinical prognosis indicators of RM group and non-RM group

Clinical prognosis indicators of two groups of patients are shown in [Table 5]. 28-day mortality of RM group and non-RM group were 25.0% and 28.9% (P>0.05) respectively, and the survival curve [Figure 2] was not statistically different between two groups of patients (P>0.05). Besides, ICU mortality (25.0% vs. 26.3%) and in-hospital mortality (36.1% vs. 39.5%) were not statistically different between RM group and non-RM group (P>0.05). Mechanical ventilation time, ICU time and in-hospital time of RM group and non-RM group were 10(6–18.75) vs. 14.5(7–23.25), 10(9.25–25.25) vs. 16.5(11–26.25) and 16(12–28.5) vs. 26(16–32.5) respectively and not statistically different (P>0.05). The incidence of common ARDS complications refractory hypoxemia (11.1% vs. 10.5%), refractory acidosis (13.9% vs. 10.5%) and barotraumas or pneumothorax (11.1% vs. 13.2%) were not statistically different between RM group and non-RM group (P>0.05).
Figure 2: 28 d survival curve of RM group and non-RM group.

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Table 5: Comparison of clinical results between RM group and non-RM group.

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  4. Discussion Top


It is found in the study that for the mechanical ventilation treatment of ARDS patients, protective lung ventilation strategy combined with lung RM (compared with no implementation of lung RM), can significantly improve patients' oxygenation index on D7, but failed to improve the 28-day mortality, hospital stay, incidence of complications and other prognostic indicators.

One of the important pathophysiological characteristics of ARDS is massive alveolar collapse, and significantly smaller effective lung volume[1],[14]. The protective lung ventilation strategy of small tidal volume ventilation can reduce platform pressure and decrease the ventilator-associated lung injury and ARDS mortality, but it is not good for the re-expansion of collapsed alveoli in patients with ARDS, and therefore, adopting a certain maneuver for lung RM may promote the collapsed alveolus recruitment, improve oxygenation, reduce intrapulmonary shunt, and even reduce mortality[14],[15],[16],[17],[18],[19]. There are many common clinical types of lung RMs, such as sustained inflation, sighing respiration, high-frequency oscillatory ventilation, PEEP incremental method, etc., the principles are not the same, but the ultimate goal is to reopen the collapsed alveoli[20].

It has been more than 20 years since Lanchman first proposed the lung RM concept and applied it in clinical practice in 1992[21]. During two decades, the lung RMs emerge in endlessly, but it is still inconclusive in both animal experiments and clinical research whether lung recruitment can improve the prognosis of patients with ARDS. It shows in the study that the lung recruitment failed to improve the patient's main outcome indicators and secondary indicators. The conclusions of previous clinical studies are also different, some studies show that lung recruitment can improve patients' clinical outcomes, such as reducing mortality in patients with ARDS and shortening hospitalization time, but another part of the studies indicate that lung recruitment can not improve the prognosis of patients with ARDS[9],[10],[22]. The reasons of contradictory results may be related to a variety of factors such as the different ARDS causes, severity, ventilation strategies, respirator parameter setting and the lung RMs in different studies[3],[22]. Therefore, the reaction of different patients with ARDS shows high heterogeneity to lung recruitment, the same lung RM may benefit some patients, but cause excessive alveolar expansion in another part of patients and aggravate the ARDS, thus offsetting the possible benefits from lung recruitment[23].

In addition, with people's understanding of pathophysiological mechanisms of ARDS, the researchers have found that different types of ARDS patients react differently towards mechanical ventilation and drug intervention. At present, one popular classification is to divide the ARDS into pulmonary ARDS and extrapulmonary ARDS[24]. The main pathological mechanism of pulmonary ARDS is primary alveolar damage; and the main mechanism of extrapulmonary ARDS is the pulmonary capillary endothelial injury caused by extrapulmonary factors[25],[26]. However, a series of studies based the classification system failed to achieve consistent conclusion in radiological manifestations, the degree of lung inflammation, reactivity to respiratory therapy, in-hospital mortality, and so on in the two subtypes of ARDS patients[27],[28]. Most scholars believe that extrapulmonary ARDS reactivity to lung recruitment is much better than pulmonary ARDS[29],[30], and a multi-center study in 2007 shows that the pulmonary ARDS and extrapulmonary ARDS reactivity to lung recruitment are similar[31]. In this study, it was found that the inducing factors of ARDS in some patients include both pulmonary factors and extrapulmonary factors, so it is difficult to further define what subtype of ARDS patients can benefit more from lung recruitment strategy.

Although it is found in this study that the lung recruitment strategy cannot improve clinical outcomes in patients with ARDS, it is found that the lung recruitment can improve the oxygenation in patients with ARDS. PaO2 of lung recruitment group rises gradually from D1 to D7 when compared with PaO2 of non-lung recruitment group. And as far as the PaO2/FiO2 is concerned, this trend is more obvious, and the PaO2/FiO2 of lung recruitment group on D7 is significantly higher than that of non-lung recruitment group. This is because that in order to prevent the oxygen toxicity and pulmonary atelectasis caused by continuous high-concentration oxygen intake, the mechanical ventilation should reduce FiO2 as far as possible while maintaining enough oxygenation in patients, so for some patients, the improvement of oxygenation is not necessarily embodied in the rise of PaO2, and may also be in the reduction of FiO2. Therefore, PaO2/FiO2 can more comprehensively reflect the oxygenation improvement during mechanical ventilation in patients with ARDS. A similar situation is also reported in abroad study, high PEEP, persistent lung expansion, CPAP and other lung recruitment strategies can all improve the patient's PaO2 and improve oxygenation, and this effect is most apparent within 30 min-2 h after lung recruitment, and then gradually falls back to the levels before recruitment[8],[10],[32].[33].

Lung recruitment can not only influence the patient's oxygenation, but also has certain influence on the patients' hemodynamics. The study of Lim and others shows that implementation of lung RM can lead to real-time drop of cardiac output and mean arterial pressure, but they can return to normal after 5–15 min[34]. As the immediate effect of the lung recruitment influence on hemodynamics has been explored in foreign articles, our research focused on whether the lung recruitment has continuous influence on hemodynamics, and the results showed that 2 h after the lung RM in lung recruitment group, the hemodynamic indexes were not significantly different from those of non-lung recruitment group, which indicates that the lung recruitment influence on the hemodynamics is temporary. This temporary hemodynamic change may be related to the returned blood volume decrease caused by transient intrathoracic pressure increase during lung recruitment.

To sum up, protective lung ventilation strategy combined with lung RM can improve the indicators such as PaO2, FiO2 and PaO2/ FiO2 on D7, but failed to improve the final outcomes such as 28-day mortality, ICU mortality and in-hospital mortality.

Conflict of interest statement

We declare that we have no conflict of interest.


  Acknowledgement Top


This work was funded by the Effect and Mechanism of Nrf2/ARE Pathway in Hydrogen Treatment of Seawater Drowning-induced Acute Lung Injury (No: 2016QN19).



 
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  In this article
Abstract
1. Introduction
2. Materials and...
3. Results
4. Discussion
Acknowledgement
References
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