Abstract
Objectives: To characterize different modes of pressure- or volume-controlled mechanical ventilation with respect to their short-term effects on oxygen delivery (DO2). Furthermore to investigate whether such differences are caused by differences in pulmonary gas exchange or by airway-pressure-mediated effects on the central hemodynamics.Design: After inducing severe respiratory distress in piglets by removing surfactant, 5 ventilatory modes were randomly and sequentially applied to each animal.Setting: Experimental laboratory of a university department of Anesthesiology and Intensive Care.Animals: 15 piglets after repeated bronchoalveolar lavage.Interventions: Volume-controlled intermittent positive-pressure ventilation (IPPV) with either 8 or 15 cmH2O PEEP; pressure-controlled inverse ratio ventilation (IRV); pressure-controlled high-frequency positive-pressure ventilation (HFPPV) and pressure-controlled high frequency ventilation with inspiratory pulses superimposed (combined high frequency ventilation, CHFV). The prefix (L) indicates that lavage has been performed.Measurements and results: Measurements of gas exchange, airway pressures, hemodynamics, functional residual capacity (using the SF6 method), intrathoracic fluid volumes (using a double-indicator dilution technique) and metabolism were performed during ventilatory and hemodynamic steady state. The peak inspiratory pressures (PIP) were significantly higher in the volume-controlled low frequency modes (43 cmH2O for L-IPPV-8 and L-IPPV-15) than in the pressure-controlled modes (39 cmH2O for L-IRV, 35 cmH2O for L-HFPPV and 33 cmH2O for L-CHFV, with PIP in the high-frequency modes being significantly lower than in inverse ratio ventilation). The mean airway pressure (MPAW) after lavage was highest with L-IRV (26 cmH2O). In the ventilatory modes with a PEEP>8 cmH2O PaO2 did not differ significantly and beyond this “opening threshold” MPAW did not further improve PaO2. Central hemodynamics were depressed by increasing airway pressures. This is especially true for L-IRV in which we found the highest MAPW and at the same time the lowest stroke index (74% of IPPV).Conclusions: In this model, as far as oxygenation is concerned, it does not matter in which specific way the airway pressures are produced. As far as oxygen transport is concerned, i.e. aiming at increasing DO2, we conclude that optimizing the circulatory status must take into account the circulatory influence of different modes of positive pressure ventilation.
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Nielsen JB, Sjöstrand UH, Edgren EL, Lichtwarck-Aschoff M, Svensson BA (1991) An experimental study of different ventilatory modes in piglets in severe respiratory distress induced by surfactant depletion. Intensive Care Med 17:225–233
Nielsen JB, Sjöstrand UH, Henneberg SW (1991) An experimental randomized study of six different ventilatory modes in a piglet model with normal lungs. Intensive Care Med 17:169–174
Sjöstrand UH (1977) A review of the physiological rationale for and development of high-frequency positive-pressure ventilation-HFPPV. Acta Anaesth Scand [Suppl] 64:7–27
Sjöstrand UH (1989) In what respect does high frequency positive pressure ventilation differ from conventional ventilation? Acta Anaesth Scand 33 [Suppl] 90:5–12
Sjöstrand UH (1989) High frequency positive pressure ventilation. Problems Respir Care 2:1
Reynolds EOR (1971) Effect of alterations in mechanical ventilator setting on pulmonary gas exchange in hyaline membrane disease. Arch Dis Child 46:152–159
Lachmann B, Danzmann E, Haendly B, Jonson B (1982): Ventilatory settings and gas exchange in respiratory distress syndrome. In: Prakash O (ed) Applied physiology in clinical respiratory care. Nijhoff, The Hague Boston London, p 141
Baum M, Benzer H, Mutz M, Pauser G, Tonczar L (1980) Inverse ratio ventilation (IRV): Die Rolle des Atemzeitverhältnisses in der Beatmung beim ARDS. Anaesthesist 29:592–596
El-Baz N, Faber LP, Doolas A (1983) Combined high frequency ventilation formanagement of terminal respiratory failure: a new technique. Anaesth Analg 62:39–49
Borg UR, Belzberg H, Blevins S (1989) Combined high frequency ventilation (CHFV). Acta Anaesth Scand 33 [Suppl] 90:155–157
Froese AB, Bryan AC (1987) High frequency ventilation. Am Rev Respir Dis 135:1363–1374
Carlon GC, Kahn RC, Howland WS, Ray C Jr, Turnbull AD (1981) Clinical experience with high frequency jet ventilation. Crit Care Med 9:1–6
Lachmann B, Schairer W, Hafner M, Armbruster S, Jonson B (1989) Volume-controlled ventilation with superimposed high frequency ventilation during expiration in healthy and surfactant-depleted pig lungs. Acta Anaesth Scand 33 [Suppl] 90:117–119
Boynton BR, Mannino FL, Davis RF, Kopotic RJ, Friedrichsen G (1984) Combined high frequency oscillatory ventilation and intermittent mandatory ventilation in critically ill neonates. J Pediatr 105:297–302
Suter PM, Laverrière MC, Pittet JF (1987) Combined high-frequency and conventional mechanical ventilation. In: Bergmann H, Steinbereithner K (eds) Beiträge zur Anästhesiologie und Intensivmedizin, vol. 21. Springer, Berlin Heidelberg New York, pp 254–258
Zeravik J, Eckart J, Zimmermann G, Blümel G, Pfeiffer UJ, Wellhöfer H (1989) Indications for combined high frequency ventilation in clinical use. Acta Anaesth Scand 33 [Suppl] 90:149–152
Mathay MA (1989) New modes of mechanical ventilation for ARDS. How should they be evaluated? Chest 95:1175
Hedenstierna G, Strandberg A, Brismar B, Lundquist H, Svensson L, Tokics L (1985) Functional residual capacity, thoracoabdominal dimensions and central blood volume during general anesthesia with muscle paralysis and mechanical ventilation. Anesthesiology 62:247–254
Gattinoni L, Pesenti A, Torresin A, Baglioni S, Rivolta M, Vesconi S, Fumagalli R, Rossli GP, Mascheroni D (1986) Morphological and functional response to PEEP in acute respiratory failure. In: Vincent JL (ed) Update in intensive care and emergency medicine. Springer, Berlin Heidelberg New York Tokyo, pp 108–111
Gattinoni L, Mascheroni D, Torresin A, Marcolin R, Fumagalli R, Vesconi S, Rossi GP, Rossi F, Baglioni S, Bassi F, Nastri G, Pesenti A (1986) Morphological response to positive endexpiratory pressure in acute respiratory failure. Computerized tomography study. Intensive Care Med 12:137–142
Pfeiffer UJ, Birk M, Aschenbrenner G, Blümel G (1982) The system for quantification of thermal-dye extravascular lung water. In: Prakash O (ed) Computers in critical care and pulmonary medicine, vol 2. Plenum, London, pp 123–125
Pfeiffer UJ, Zimmermann G (1984) Fehlermöglichkeiten und Grenzen der Lungenwasserbestimmung mit der Thermo-Dye-Technik. Beitr Anaesthesiol Intensivmed 6:81–104
Pfeiffer U, Birk M, Aschenbrenner G, Petrowicz O, Blümel G (1980) Validity of the thermal-dye-technique for measurements of extravascular lung water. Eur Surg Res 12 [Suppl]:106–107
Lewis FR, Elings VB (1978) Microprocessor determination of lung water using thermal-green dye double indicator dilution. Surg Forum 29:182–184
Newmann EV, Merell MM, Genecin A, Monge C, Milnor WR, McKeever WP (1951) The dye dilution method for describing the central circulation. An analysis of factors shaping the time-concentration curves. Circulation 6:735–746
Wickerts CJ, Jacobsson J, Frostell C, Hedenstierna G (1990) Measurement of extravascular lung water by thermal-dye dilution technique: mechanisms of cardiac output dependence. Intensive Care Med 16:115–120
Lachmann B, Robertson B, Vogel J (1980) In vivo lung lavage as an experimental model of the respiratory distress syndrome Acta Anaesth Scand 24:231–236
Jonmarker C, Castor R, Drefeldt B, Werner O (1985) An analyzer for in-line measurement of expiratory sulfur hexafluoride concentration. Anesthesiology 63:84–88
Larsson A, Linnarsson D, Jonmarker C, Jonson B, Larsson H, Werner O (1987) Measurement of lung volume by sulfur hexafluoride washout during spontaneous and controlled ventilation. Further development of a method. Anesthesiology 67:543–550
Larsson A, Jonmarker C, Werner O (1988) Ventilation inhomogeneity during controlled ventilation. Which index should be used? J Appl Physiol 65:2030–2039
Gattinoni L, Pesenti A, Mascheroni D, Marcolin R, Fumagali R, Rossi F, Iapichino G, Romagnoli B, Uziel L, Agostoni A, Kolobow T, Damia G (1986) Low frequency positive pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure. JAMA 256:881–886
Snyder JV, Froese AB (1987) The open lung approach: concept and application. In: Oxygen transport in the critically ill patient. Year Book Medical Publishers, Chicago London, pp 374–395
Hickling KG, Henderson S, Jackson R (1990) Low mortality associated with low volume pressure limited ventilation with permissive hypercapnia in severe adult respiratory distress syndrome. Intensive Care Med 16:372–377
Coalson JJ, deLemos RA (1989) Pathologic features of various ventilatory strategies. Acta Anaesth Scand 33 [Suppl] 90:108–116
Hickling KG (1990) Ventilatory management of ARDS: can it affect outcome? Intensive Care Med 16:219–226
Pfeiffer UJ, Perker M, Zeravik J, Zimmermann G (1990) Sensitivity of central venous pressure, pulmonary capillary wedge pressure, and intrathoracic blood volume as indicators for acute and chronic hypovolemia. In: Lewis FR, Pfeiffer UJ (eds) Practical applications of fiberoptics in critical care monitoring. Springer, Berlin Heidelberg New York, pp 25–31
Shoemaker WC, Kram HB, Appel PL (1990) Therapy of shock based on pathophysiology, monitoring and outcome prediction. Crit Care Med 18:S19-S25
Siggard-Andersen O (1980) Determination and presentation of acid-base data. Contr Nephrol 21/20:128–136
Fusciardi J, Rouby JJ, Benhamou D, Viars P (1984) Hemodynamic consequences of increasing mean airway pressures during high frequency jet ventilation. Chest 86:30–34
Fusciardi J, Rouby JJ, Barakat T, Mal H, Godet G, Viars P (1986) Hemodynamic effects of high-frequency jet ventilation in patients with and without circulatory shock. Anesthesiology 65:485–491
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Lichtwarck-Aschoff, M., Nielsen, J.B., Sjöstrand, U.H. et al. An experimental randomized study of five different ventilatory modes in a piglet model of severe respiratory distress. Intensive Care Med 18, 339–347 (1992). https://doi.org/10.1007/BF01694362
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DOI: https://doi.org/10.1007/BF01694362