Chest
Volume 114, Issue 3, September 1998, Pages 834-838
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laboratory and animal investigations
The Physiologic Effects of Inverse Ratio Ventilation

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Study objectives: The efficacy of inverse ratio ventilation in ARDS is not clear. Furthermore, the mechanism responsible has not been determined. We designed an animal study to determine if inverse ratio ventilation improves gas exchange and by what mechanism.

Design: Prospective randomized, controlled design was used.

Setting: University of Missouri Pulmonary/Critical Care Animal Laboratory.

Participants: Nine dogs with oleic acid-induced lung injury as control animals to assess stability of the model, nine in the experimental model.

Interventions: Conventional ventilation with full recruitment extrinsic positive end-expiratory pressure (PEEP) was compared with two other modes of ventilation. One was inverse ratio with extrinsic PEEP and the second was inverse ratio with intrinsic PEEP equal to full recruitment PEEP. Full recruitment levels of PEEP were defined by optimizing compliance, then increasing PEEP by 2.5 cm/H2O. Each type of ventilation was maintained for 45 min after the edema had stabilized. Comparison of lung injury over time requires stability of the model over time. Therefore, we also assessed the stability of the preparation over time by examining compliance, extravascular lung water, and venous admixture in nine control dogs with equivalent lung injury over the same time span.

Measurements and results: Mean airway pressure was increased by both types of inverse ratio ventilation, while compliance remained stable. Venous admixture was reduced (conv=0.32±0.12, inverse ratio with extrinsic PEEP=0.24±0.10, inverse ratio with intrinsic PEEP=0.28±0.11) with inverse ratio with extrinsic PEEP, but the improvement was less with inverse ratio with intrinsic PEEP, even though the mean airway pressure was higher.

Conclusions: We conclude that increasing mean airway pressure by prolongation of the inspiratory time improves gas exchange in our model of ARDS, but when mean airway pressure is increased further, allowing the development of intrinsic PEEP, the beneficial effects on gas exchange are less. Increasing mean airway pressure with intrinsic PEEP is not equivalent to other methods of increasing mean airway pressure.

(CHEST 1998; 114:834–838)

Abbreviations: EVLW= extravascular lung water; I/E=inspiratory/expiratory; IRV=inverse ratio ventilation; LVDPDT=rate of left ventricular systolic pressure change at 40 mm Hg; PEEP=positive end-expiratory pressure; Q˙S/Q˙T=venous admixture; VD/VT=dead space

Section snippets

Experimental Preparation

Nine male, mongrel dogs were anesthetized with pentobarbital (10 mg/kg bolus and 10 mg/kg continuous infusion) after induction with the ultrashort-acting barbiturate thiopental (15 mg/kg). The animals were intubated with an 8.0-mm cuffed endotracheal tube, ventilated with 18 ml/kg tidal volume, and a fraction of inspired oxygen of 1.0 with a ventilator (Bear 2; Cambridge, MA). The rate was adjusted to maintain a normal PaCO2. The animals were then instrumented. Instrumentation included

RESULTS

The oleic acid induced significant lung injury, with wet lung weights of 43.6±5.5 g/kg and dry lung weights of 3.4±0.8 g/kg in the nine experimental dogs (average weight, 22.4±5.5 kg).

DISCUSSION

When mean airway pressure was increased with inverse ratio with extrinsic PEEP, there was a reduction in Q˙S/Q˙T and VD/VT compared with conventional ventilation with full recruitment levels of extrinsic PEEP. When mean airway pressure was increased still further with inverse ratio with intrinsic PEEP, there was an increase in Q˙S/Q˙T relative to inverse ratio with extrinsic PEEP. These results suggest that all methods of increasing mean airway pressure are not equivalent. In

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Manuscript received September 5, 1997; revision accepted February 4, 1998.

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