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Review
. 2011 Apr 7;15(2):304.
doi: 10.1186/cc10052.

Beyond volutrauma in ARDS: the critical role of lung tissue deformation

Guillermo M Albaiceta  1 , Lluis Blanch
Affiliations
Review

Beyond volutrauma in ARDS: the critical role of lung tissue deformation

Guillermo M Albaiceta et al. Crit Care. .

Abstract

Ventilator-induced lung injury (VILI) consists of tissue damage and a biological response resulting from the application of inappropriate mechanical forces to the lung parenchyma. The current paradigm attributes VILI to overstretching due to very high-volume ventilation (volutrauma) and cyclic changes in aeration due to very low-volume ventilation (atelectrauma); however, this model cannot explain some research findings. In the present review, we discuss the relevance of cyclic deformation of lung tissue as the main determinant of VILI. Parenchymal stability resulting from the interplay of respiratory parameters such as tidal volume, positive end-expiratory pressure or respiratory rate can explain the results of different clinical trials and experimental studies that do not fit with the classic volutrauma/atelectrauma model. Focusing on tissue deformation could lead to new bedside monitoring and ventilatory strategies.

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Figures

Figure 1
Figure 1
Influence of ventilatory settings in alveolar stability. Differences between end-expiratory and end-inspiratory alveolar size increase with tidal volume and decrease with positive end-expiratory pressure (PEEP) (measured in an experimental model of lung injury). Note the synergistic relationship between these two parameters, and that PEEP may decrease the change in size in spite of high tidal volumes. Data extracted from [38].
Figure 2
Figure 2
Effects of recruitment in alveolar stability. Alveolar stability can be achieved by the equilibrium between end-inspiratory and end-expiratory volumes. This stability allows definition of a hypothetical safe zone (blue area). Because strain can be viewed as the ratio between these volumes, this zone corresponds to normal or lower strain values. On the contrary, excessive end-inspiratory deformation in lungs with a low resting volume leads to alveolar instability (red area). The arrows represent how the tidal volume (Vt) and positive end-expiratory pressure (PEEP) modify the end-inspiratory/end-expiratory ratio. In recruitable lungs, PEEP induces an increase in end-expiratory lung volume that allows ventilation to stay in the safe zone, and strain decreases. In the absence of recruitment, however, both the Vt and PEEP lead to a predominant increase in end-inspiratory volume, therefore increasing strain. FRC, functional residual capacity.
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