Lung Recruitment in Patients with the Acute Respiratory Distress Syndrome

TLDR

In ARDS, positive end‑expiratory pressure may reduce ventilator‑induced lung injury by preventing collapse of lung regions. The authors investigated how the percentage of potentially recruitable lung, measured by computed tomography, relates to the clinical and physiological effects of PEEP in 68 patients with acute lung injury or ARDS. They performed whole‑lung CT scans at airway pressures of 5, 15, and 45 cm H₂O during breath‑holding to quantify recruitable lung tissue. The proportion of recruitable lung varied widely (mean 13 ± 11 % of lung weight), correlated strongly with PEEP‑induced aeration (r² = 0.72), and patients with higher recruitability (>9 %) exhibited worse oxygenation, lower compliance, higher dead space, greater lung weight, and increased mortality, with physiological variables predicting recruitability status with 71 % sensitivity and 59 % specificity.

Abstract

In the acute respiratory distress syndrome (ARDS), positive end-expiratory pressure (PEEP) may decrease ventilator-induced lung injury by keeping lung regions open that otherwise would be collapsed. Since the effects of PEEP probably depend on the recruitability of lung tissue, we conducted a study to examine the relationship between the percentage of potentially recruitable lung, as indicated by computed tomography (CT), and the clinical and physiological effects of PEEP.Sixty-eight patients with acute lung injury or ARDS underwent whole-lung CT during breath-holding sessions at airway pressures of 5, 15, and 45 cm of water. The percentage of potentially recruitable lung was defined as the proportion of lung tissue in which aeration was restored at airway pressures between 5 and 45 cm of water.The percentage of potentially recruitable lung varied widely in the population, accounting for a mean (+/-SD) of 13+/-11 percent of the lung weight, and was highly correlated with the percentage of lung tissue in which aeration was maintained after the application of PEEP (r2=0.72, P<0.001). On average, 24 percent of the lung could not be recruited. Patients with a higher percentage of potentially recruitable lung (greater than the median value of 9 percent) had greater total lung weights (P<0.001), poorer oxygenation (defined as a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen) (P<0.001) and respiratory-system compliance (P=0.002), higher levels of dead space (P=0.002), and higher rates of death (P=0.02) than patients with a lower percentage of potentially recruitable lung. The combined physiological variables predicted, with a sensitivity of 71 percent and a specificity of 59 percent, whether a patient's proportion of potentially recruitable lung was higher or lower than the median.In ARDS, the percentage of potentially recruitable lung is extremely variable and is strongly associated with the response to PEEP.