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Reversal of dependent lung collapse predicts response to lung recruitment in children with early acute lung injury

Wolf, Gerhard K. MD; Gómez-Laberge, Camille PhD; Kheir, John N. MD; Zurakowski, David PhD; Walsh, Brian K. RRT-NPS; Adler, Andy PhD; Arnold, John H. MD

Pediatric Critical Care Medicine: September 2012 - Volume 13 - Issue 5 - p 509–515
doi: 10.1097/PCC.0b013e318245579c
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Objective: To describe the resolution of regional atelectasis and the development of regional lung overdistension during a lung-recruitment protocol in children with acute lung injury.

Design: Prospective interventional trial.

Setting: Pediatric intensive care unit.

Patients: Ten children with early (<72 hrs) acute lung injury.

Interventions: Sustained inflation maneuver (positive airway pressure of 40 cm H2O for 40 secs), followed by a stepwise recruitment maneuver (escalating plateau pressures by 5 cm H2O every 15 mins) until physiologic lung recruitment, defined by PaO2 + PaCO2 ≥400 mm Hg, was achieved. Regional lung volumes and mechanics were measured using electrical impedance tomography.

Measurements and Main Results: Patients that responded to the stepwise lung-recruitment maneuver had atelectasis in 54% of the dependent lung regions, while nonresponders had atelectasis in 10% of the dependent lung regions (p = .032). In the pressure step preceding physiologic lung recruitment, a significant reversal of atelectasis occurred in 17% of the dependent lung regions (p = .016). Stepwise recruitment overdistended 8% of the dependent lung regions in responders, but 58% of the same regions in nonresponders (p < .001). Lung compliance in dependent lung regions increased in responders, while compliance in nonresponders did not improve. In contrast to the stepwise recruitment maneuver, the sustained inflation did not produce significant changes in atelectasis or oxygenation: atelectasis was only reversed in 12% of the lung (p = .122), and there was only a modest improvement in oxygenation (27 ± 14 mm Hg, p = .088).

Conclusions: Reversal of atelectasis in the most dependent lung region preceded improvements in gas exchange during a stepwise lung-recruitment strategy. Lung recruitment of dependent lung areas was accompanied by considerable overdistension of nondependent lung regions. Larger amounts of atelectasis in dependent lung areas were associated with a positive response to a stepwise lung-recruitment maneuver.

From the Division of Critical Care Medicine (GKW, CGL, JHA), Departments of Anesthesiology, Perioperative and Pain Medicine (DZ), and Cardiology (JNK), Children’s Hospital Boston, Harvard Medical School, Boston, MA; Department of Respiratory Care (BKW), Children’s Medical Center, Dallas, TX; Department of Systems and Computer Engineering (AA), Carleton University, Ottawa, Canada.

Supported, in part, by the Department of Anesthesiology, Perioperative and Pain Medicine, the Translational Research Program, both at Children’s Hospital Boston.

The authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: gerhard.wolf@childrens.harvard.edu

©2012The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies