The open lung during small tidal volume ventilation: Concepts of recruitment and "optimal" positive end-expiratory pressure

Objectives: To test the hypotheses that during small tidal volume ventilati on (5 mL/kg) deliberate volume recruitment maneuvers allow expansion of ate lectatic lung units and that a high positive end-expiratory pressure (PEEP) above the lower inflection point of the pressure/volume (PV) curve is not necessarily required to maintain recruited lung volume in acute lung injury . Design: Prospective, randomized, controlled animal study. Setting: An animal laboratory in a university setting. Subjects: Adult New-Zealand rabbits. Interventions: We studied a) the relationship of dynamic loops during inter mittent positive pressure ventilation to the quasistatic PV curve, and b) t he effect of lung recruitment on oxygenation, end-expiratory long volume (E ELV), and dynamic compliance in two groups (n = 4 per group) of lung-injure d animals (lung lavage model): 1) the sustained inflation group, which rece ived ventilation after a recruitment maneuver (sustained inflation); and 2) the control group, which received ventilation without any lung recruitment . Measurements and Main Results: In the presence of PV hysteresis, a single s ustained inflation to 30 cm H2O boosted the ventilatory cycle onto the defl ation limb of the PV curve. This resulted in a significant increase in EELV , oxygenation, and dynamic compliance despite equal PEEP levels used before and after the recruitment maneuver. Furthermore, after a single sustained inflation, oxygenation remained high over 4 hrs of ventilation when a PEEP above the critical closing pressure of the lungs, defined as "optimal" PEEP , was used and was significantly higher compared with that in the control g roup ventilated at equal PEEP without preceding lung recruitment. Conclusions: The observation that ventilation occurs on the deflation limb of the tidal cycle-specific PV curve allows placement of the ventilatory cy cle, by means of a recruitment maneuver, onto the deflation limb of the PV envelope of the optimally recruited lung. This strategy ensures sufficient lung volume recruitment to maintain the lungs during the tidal cycle while using relatively low airway pressures.