POCKET GUIDE

LUNG RECRUITMENT

C RITICAL CAR E

CONTENT

3
4
7
8
9
10
11
12
13
13
14
15
15
16
17
17
18
19

Content
Ventilator-Induced Lung Injury (VILI)
Pressure Control Ventilation
Golden Moment: Late Inspiratoy Recruitment
The Open Lung Tool
Open Lung Tool Parameters
Cursor Function
Zoom Function
Clinical Application of Cdyn i
Opening of collapsed airways and alveoli
PEEP titration
Evaluation of intervention
Monitoring
Clinical Application of VTCO2
Opening of collapsed airways and alveoli
PEEP titration
A Lung Recuitment maneuver
References

VENTILATOR-INDUCED LUNG INJURY (VILI)

The ventilator strategy makes a major difference in outcome. Largescale, randomised, clinical trials demonstrates that the way patients
are ventilated can markedly affect outcome, presumably by decreasing
Ventilator-Induced Lung Injury (VILI).
Traditional ventilation patterns with high tidal volumes and low
PEEP has been postulated to be important mechanisms for inducing
and maintaining inflammatory reactions in the lung. The fact that this
initial local reaction eventually may migrate to other organ of the body and
induce a secondary failure in remote organs is increasingly recognized.
It is well established that mechanical ventilation may initiate or augment
injury to the lung tissue (VILI). These so-called barotrauma or volutrauma
are caused either by one or, most probably, by a combination of the
following factors:
High inflation pressures
High tidal volumes
Continuous expansion and collapse of alveoli
Shear forces

ARDS Survival: ARDSNet Trial

The Survival rate was increased nearly 22% when the patients were ventilated with lower
tidal volumes. This is not depending on the lower tidal volume in itself. The lower tidal
volume is decreasing the heterogenic injury and the heterogenic mortality. (Prof. Slutsky)

VILI
The inflammatory reaction induced by the mechanical insult on the lung,
may further aggravate the injury by production of a multitude of proinflammatory substances. Migration of these inflammatory mediators
to other organ systems may induce secondary organ dysfunction
(biotrauma).
What Causes Ventilator Induced Lung Injury?
Volutrauma/ Barotrauma / Shear Force
Leaky Alveolar Capillary Membrane
Surfactant Deactivation
Cytokine and Mediator Release
RACE Repetitive Alveolar Collapse and Expansion

Mechanical Ventilation can

lead to Biophysical injury
Shear force
Overdistention
Cyclic Stretch
Intrathoracic pressure

Biochemical Injury
Pro-inflammatory mediators migrating
to other organ systems through the systemic circulation may induce secondary organ dysfunction and potentially
increase mortality.

The hemodynamic consequences

Increased Alveolar-Capillary
Permeability
Decreased Cardiac Output
Decreased Organ Perfusion

VILI

Open up the lung and keep the lung open from Professor Lachmanns
editorial (1) has been quoted many times. The Open lung is characterized
by an optimal gas exchange (1). The intrapulmonary shunt is ideally less
than 10%, which corresponds to a PaO2 of more than 450mmHg on pure
oxygen (4-6) at the same time airway pressure are at the minimum to
ensure the required gas exchange. Hemodynamic side effects are thus
minimized (1,7).
Approaches to Lung Protective Ventilation
Recruitment Maneuvres
PEEP> Critical Closing Pressure (CCP)
Low tidal Volumes
Pressure Control Ventilation
Lung recruitment has gained widespread interest as a procedure for
the opening of closed lung units. The widespread use of low tidal
volumes may increase the risk of generation of atelectasis in the
basal parts of the lung, which eventually may lead to consolidation
of the affected areas. Further deterioration is caused by high inhaled
oxygen concentrations resulting in reabsorbtion atelectasis. In certain
patients, the use of a recruitment maneuvre may provide a long-term
improvement in oxygenation. If proper PEEP level can be determined
and set, the effect will stabilize and further protect the lung by avoiding
cyclic opening and closing of lung units.
It is important to choose a mode of ventilation that minimizes the
stress of the lung tissue.

PRESSURE CONTROL VENTILATION

Pressure control ventilation

Pressure control ventilation is recommended, as in this mode of ventilation
the ventilator delivers a flow that maintains the preset pressure during the
preset inspiratory time. The pressure is constant during the inspiratory
time and the flow is decelerating.
If for any reason pressure tends to decrease during inspiration the
flow from the ventilator will immediately increase to maintain the set
inspiratory pressure. The Servo-i will sense the smallest deviations in
pressure. If it appears that previously collapsed units of the lung are
starting to open in the late phase of inspiration the pressure tends to
decrease, this is compensated by a precise increase in flow and the
alveoli are opened.

LATE INSPIRATORY RECRUITMENT

Golden Moment: Late Inspiratory Recruitment
Terminal airway resistance decreases in discrete steps when the pressure
is applied. The behavior of lung opening is comparable to a multitude
of pressure- and time-dependent avalanches. By immediately sensing
the pressure drop induced by an opening avalanche, Servo-i provides
proper flow to balance and further enhance the opening process.

A minute pressure drop induced

by a fractional opening of closed
airways is immediately sensed by
Servo-i, resulting in a corresponding increase in inspiratory flow
delivery. This promotes gas distribution to potentially recruitable
areas and gives a gentle opening
of previously collapsed areas.
A low sampling rate during
this situation will result in a larger
pressure drop with a resultant overshoot in flow delivery. This may
rip the airways open and give an
immediate rebound by the then
induced tissue stress in adjacent
areas.

Late Inspiratory Recruitment

THE OPEN LUNG TOOL

The Open Lung Tool
The Open Lung Tool is a real-time monitoring option that looks at the
changes in Lung Mechanics during the clinical application of a recruitment
strategy.
The Open Lung Tool (OLT) can be used for graphical visualization
of measured and calculated values for easier interpretation of patient
response to user controlled lung recruitment procedures. The OLT can
also be used as a breath-by-breath trend monitor of collected and
stored parameter data.

Open Lung Tool (option)

This tool is reached and displayed via the Quick access
fixed key. However, data are collected continuously at all
times when the Servo-i is in operation.
Upon selection, the three graph windows are auto
scaled vertically. The scaling can be set manually via
Quick access/Open Lung Tool scales.

OPEN LUNG TOOL PARAMETERS

OLT parameters
OLT allows for a graphical breath-by-breath observation of End
Inspiratory Pressure and PEEP, inspired and expired tidal volumes,
dynamic compliance and Tidal CO 2 elimination. Please observe when
the CO2 Analyzer Servo-i is installed and connected.
Three synchronous graphical trend windows are presented with a
fixed set of parameters as a function of collected breaths over time. This
alternative presentation may be used for immediate visualization of the
effect of altered ventilator settings.

The following parameters are presented:

In the upper window, measured End Inspiratory Pressure (EIP) and
Positive End Expiratory Pressure (PEEP) presented, breath-by-breath.
In the middle window, measured Inspiratory tidal volume (VTi) and
Expiratory tidal volume (VTe) presented, breath-by-breath.
In the lower window, calculated dynamic Compliance (Cdyn i) and
Tidal CO2 elimination (VTCO 2 ) presented breath-by-breath.
Cdyn i =

VTi
EIP-PEEP

It should be noted that calculation of Cdyn i as shown above results

in the compliance of the whole respiratory system. Calculation of lung
compliance requires the recording of transpulmonary pressure. That is
airway pressure minus oesophageal pressure.
10

CURSOR FUNCTION/ZOOM FUCTION

Time displayed on the lower right hand area of the screen indicates
remaining time at the current respiratory rate for the curve to fill the
available screen space. Changing the scaling with the zoom in or
out function will change the number of breaths needed for filling the
available screen space.
Cursor function
An activated cursor can be moved with the Main Rotary Dial or via the
soft keys. When moving it along the graph, the numeric parameter
values valid for that particular moment will be shown at the right hand
side of the graph.

11

CURSOR FUNCTION/ZOOM FUCTION

In this way, the corresponding values for EIP, PEEP, VTi, VTe, Cdyn i and
VTCO2 can be compared for each breath.
With the cursor active and moved to the extreme left side of the
window, the previous saved breaths time window will be displayed and
presented on the screen. Presentations must be scaled manually if values
are out of range. Stored data can be accessed while moving the cursor
to the left. Note! Scales will not be adjusted (auto scaled) during cursor
activation. Data for approximately 20 000 breaths can be stored and
reviewed in the OLT.
When the Clear function is activated, the values shown on screen
are removed allowing for new data to be presented. However, no data
are deleted from the memory, i.e. old data can still be evaluated by using
Cursor mode. (Clear cannot be used when the Cursor is activated.)
Zoom function
The zoom function allows for adapted presentations and five different
zoom levels can be chosen.

12

CLINICAL APPLICATION OF Cdyn i

Clinical Application of Cdyn i

The Servo-i OLT provides a possibility to display and store patient/

ventilator responses to a series of user-controlled patterns of changes
in ventilator settings, typically applied during a lung recruitment
procedure. The objective for such procedures is to open up airways
and alveoli that currently are collapsed and to keep them aerated also
throughout the expiratory part of the breath cycle.

Opening of collapsed airways and alveoli

Currently there are several different methods in clinical use to accomplish an opening of collapsed alveoli and the common denominator for
most of these methods is to intermittently apply an increased positive
pressure in the lung for a limited time.
13

CLINICAL APPLICATION OF Cdyn i

The graphical display of Cdyn i will indicate the response of the
patients lung mechanics to each change in applied airway pressure
and inspiratory tidal volume. For example, during a stepwise increase
of the EIP a corresponding increase in tidal volume will occur.
As long as the relative increase in EIP and tidal volume are linear the
Cdyn i will appear constant, reflecting the development of the pressure/
volume relation in the lung over time. With a continued stepwise
increase in EIP there will eventually be a slightly less increase in the
corresponding tidal volume, which is indicated by a slight decrease in
Cdyn i. Additional increase in EIP at this point may result in a gradually
smaller increase in tidal volume accompanied by a decrease in Cdyn i.
This pattern may illustrate that the relative frequency of opening of
collapsed alveoli is reduced relative to increase in pressure and that
further increase in EIP may result in overdistension of already opened
alveoli.
PEEP titration
Cdyn i may also be used to find the level of PEEP which prevents alveolar collapse during expiration (Critical Closing Pressure). Used for this
purpose it may help guiding the titration of effective PEEP. This may be
performed by a stepwise decrease of an initial high PEEP level, which
should be assessed before the recruitment maneuvre is being performed. As PEEP is stepwise decreased, the Cdyn i will initially increase
with each drop of the PEEP level indicating a relief of over distended
areas in the lung. Subsequently the Cdyn i will reach a plateau where
Cdyn i no longer increases when the PEEP level is decreased.
After further decrease in the PEEP level, the Cdyn i will start
decreasing indicating initial collapse of alveoli that no longer can be
kept open at the current PEEP level.
The cursor may be used to help identify the maximum level of Cdyn i,
and its corresponding PEEP level may be used as a reference for the
closing airway pressure. Effective PEEP should be set 2-3 cmH 2O above
the indicated collapse pressure as a safety margin after a preceding
recruitment maneuvre.

14

CLINICAL APPLICATION OF Cdyn i

Evaluation of intervention
Cdyn i may also be a good indicator of an intervention. An assessment
of the relative improvement of Cdyn i, may be done by comparing the
value before and after the intervention.
Monitoring
The breath-by-breath registration and storage of Cdyn i in the OLT will
allow for a continuous monitoring, which with the help of the cursor
can be reviewed and evaluated as an indicator of changes in the lung
mechanics.
A declining Cdyn i over time can be correlated to an ongoing
process of alveolar collapse. In cases when a significant drop in Cdyn i
can be observed, the need for a re-recruitment should be assessed.

Effect of a recruitment maneuver. Note the lack of effect with a step-wise increase in
PEEP without the recruitment maneuver.
Slide kindly provided by Fernando Sipman-Suarez: Alveolar and Airway Collapse.
Preventive measures by best PEEP titration. Symposium: Iatrogenesis of mechanical
ventilation: How to prevent it. Sydney, October 2001.

15

CLINICAL APPLICATION OF VTCO 2

Clinical application of VTCO 2

The CO2 concentration in expired air depends mainly on alveolar
ventilation, cardiac output and the metabolic state.
A large difference between arterial and end-expiratory (end-tidal)
CO2 can be caused by an alveolar dead space, as can be seen, for
example, with a pulmonary embolus. Shunt and V/Q-mismatch impede
CO2 elimination only to a minor degree and can be disregarded in this
context (very large shunts transmit mixed venous blood to the arterial
side, slightly raising arterial CO2 ).
The elimination of CO 2 via expired gas during normal conditions can
be calculated from the Brodys formula, which predicts CO2 production
during resting condition:
VCO2 (elimination/minute) = V/Qx10xBW 0.75
Using this formula for a person weighing 70 kg will give VCO2 elimination
of approximately 200ml CO2 /min. VTCO2 can be calculated by dividing
VCO2 with the respiratory rate.
In the OLT, VTCO2 is calculated by a direct integration of measured
CO2 concentration over measured expiratory flow on a breath-bybreath basis. (See equations under OLT parameters above.)
16

CLINICAL APPLICATION OF VTCO 2

Opening of collapsed airways and alveoli
When a stepwise increase of EIP is applied to a collapsed lung, the
VTCO2 will increase with each pressure step due to increased ventilation
of already opened alveoli and recruitment of collapsed areas allowing
for additional diffusion of CO2 from the blood into the alveolar space.
With a continued stepwise increase of EIP, VTCO 2 will keep
increasing until a point when no additional alveoli may be possible
to open without impeding circulation. Already opened alveoli could
also be over distended at this point, resulting in an increase in the
ventilation/perfusion ratio. At this point diffusion of CO 2 into the alveoli
will start decreasing, which primarily may be indicated as a drop in
VTCO2 and by a fall in pulmonary blood flow with subsequent fall in
systemic arterial blood pressure.
PEEP titration
VTCO2 will follow a similar pattern as described for the Cdyn i above,
when the same technique for PEEP titration (see above) is applied.

17

A LUNG RECRUITMENT MANEUVRE

Corresponding Lung Recruitment Maneuvre shown in the ordinary OLT window: (See
corresponding red circles from left to right in the picture)
1

The initial situation, with limited ventilated area within the lungs

The increased EIP, opens up closed compartments. VTCO2 (tidal elimination)

increases, as previously unventilated compartments now take part in the gas exchange.

VTCO2 reaches a plateau as no additional alveoli opens up.

PEEP is slowly decreased, step-by-step to identify the maximum value of Cdyn i as

a breaking point, where lung compartments may start to close again. Collapse
pressure is identified as the corresponding plateau/max value of Cdyn i and VTCO2.

The lung is re-recruited at initially used opening pressure.

PEEP is set 2 cmH2O above the collapse pressure.

The CO2 tidal elimination and Cdyn i were used here for evaluation and identification of
the different phases in the maneuvre.

18

REFERENCES
1. Lachmann B. Open up the lung and keep
the lung open. Intensive Care Med 1992; 118:
319-321.

conventional mechanical ventilation and

high-frequency oscillation.
Intensive Care Med.2000 Jun; 26(6):745-55.

2. Lichtwarck-Aschoff M, Nielsen JB,

Sjstrand UH, Edgren E. An experimental
randomized study of five different ventilatory
modes in a piglet model of severe respiratory distress. Intensive Care Med 1992;18:
339-347.

11. Amato MB. Barbas CS, Medeiros MD,

et al. Beneficial effects of the open lung
approach with low distending pressures
in acute respiratory distress syndrome. A
prospective randomized study on mechanical
ventilation. Am J Respir Crit Care Med 1995;
152: 1835-46.

3. Sjstrand UH, Lichtwarck-Aschoff M,

Nielsen JB, et al. Different ventilatory approaches to keep the lung open. Intensive
Care Med 1995; 21:310-8.
4. Kesecioglu J, Tibboel D, Lachmann B.
Advantages and rationale for pressure control
ventilation. In: Vincent JL (ed) Yearbook of
intensive care and emergency medicine.
Springer-Verlag; Berlin; Heidelberg, New
York, 1994; 524-533.
5. Lachmann B, Danzmann E, Haendly
B, Jonson B. Ventilator settings and gas
exchange in respiratory distress syndrome.
In: Prakash O (ed) Applied physiology in
clinical respiratory care. Nijhoff, The Hague
1982; 141-176.
6. Tusman G et al. Alveolar recruitment
strategy improves arterial oxygenation during
general anesthesia. Br J Anaesth 1999; 8-13.
7. Tusman G et al. Alveolar recruitment
strategy increases arterial oxygenation during
one-lung ventilation. Annals of Thorac Surg
2002; 73: 1204-9.
8. Tusman G et al. Effects of recruitment
maneuver on atelectasis in anesthetized children. Anesthesiology Jan 2003; 98(1): 14-22.
9. Surez Sipmann F et al. Clinical experience
from the open lung clinical trial in Spain. Journal fr Ansthesie und Intensivbehandlung
1998;1.Quartal:183-6.
10. Rimensberger PC, Pache JC,
McKerlie C,Frndova H, Cox PN.
Lung recruitment and lung volume maintenance: a strategy for improving oxygenation
and preventing lung injury during both

12. Amato MB. Barbas CS, Medeiros MD, et

al. Effect of a protective-ventilatory strategy
on mortality in the acute respiratory distress
syndrome. N Engl J Med 1998; 338: 347-54.
13. Marini J J, Gattinoni L. Ventilatory
management of acute respiratory distress
syndrome: A consensus of two.
Crit Care Med.2004 Vol.32, No1
Scientific Presentations
and publications
14. Lung recruitment in patients with
ARDS/ALI.
Art. No: 65 88 888 E315E
15. Ventilator associated treatment and monitoring of pediatric and neonatal cardiopulmonary disease.
Art. No: 64 41 989 E315E
16. Iatrogenesis of Mechanical Ventilation:
How to prevent it?
Art. No: 65 88 367 E315E
17. Mechanical Ventilation in Anesthesia &
Intensive Care. Art. No: 65 88 433 E315E
18. Biotrauma A primer on ventilator-induced inflammatory reaction.
Art. No: 65 88 938 E315E
18. Lung Recruitment PEEP and VT in ARDS.
Art. No: 66 48 864 E315E
19. Mechanical Ventilation.
Art. No: 66 48 872 E315E
20. CD collection box.
Art. No: 65 88 862 E315E

19

Maquet Critical Care AB

SE-171 95 SOLNA
Sweden
Phone: +46 8 730 73 00
www.maquet.com/criticalcare
Maquet Critical Care AB 2004. All rights reserved.
MAQUET reserves the right to modify the design and
specifications contained herein without prior notice.
Order No. 66 61 271
Printed in Sweden
1104 10.
Rev.01 English
Price: Group 1