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Acta Anaesthesiol Scand 2011; 55: 165174 Printed in Singapore.

All rights reserved

r 2010 The Authors Journal compilation r 2010 The Acta Anaesthesiologica Scandinavica Foundation ACTA ANAESTHESIOLOGICA SCANDINAVICA

doi: 10.1111/j.1399-6576.2010.02331.x

A new non-radiological method to assess potential lung recruitability: a pilot study in ALI patients
K. LOWHAGEN, S. LINDGREN, H. ODENSTEDT, O. STENQVIST and S. LUNDIN
Department of Anaesthesia and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden

Introduction: Potentially recruitable lung has been assessed previously in patients with acute lung injury (ALI) by computed tomography. A large variability in lung recruitability was observed between patients. In this study, we assess whether a new non-radiological bedside technique could determine potentially recruitable lung volume (PRLV) in ALI patients. Methods: Sixteen mechanically ventilated patients with early ALI/ARDS were subjected to a recruitment manoeuvre and decremental PEEP titration. Electric impedance tomography, together with measurements of endexpiratory lung volume (EELV) and tracheal pressure, were used to determine PRLV. The method denes fully recruited open lung volume (OLV) as the volume reached at the end of two consecutive vital capacity manoeuvres to 40 cmH 2 O. It also uses extrapolation of the baseline alveolar pressure/volume curve up to 40 cmH 2 O, the volume reached being the non-recruited lung volume. The differ-

ence between the fully recruited and the non-recruited volume was dened as PRLV. Results: We observed a considerable heterogeneity among the patients in lung recruitability, PRLV range 1147%. In a post hoc analysis, dividing the patients into two groups, a high and a low PRLV group, we found at baseline before the recruitment manoeuvre that the high PRLV group had lower compliance and a lower fraction of EELV/OLV. Conclusions: Using non-invasive radiation-free bedside methods, it may be possible to measure PRLV in ALI/ ARDS patients. It is possible that this technique could be used to determine the need for recruitment manoeuvres and to select PEEP level on the basis of lung recruitability.
Accepted for publication 14 September 2010 r 2010 The Authors Journal compilation r 2010 The Acta Anaesthesiologica Scandinavica Foundation

T has been shown that a positive response to a lung recruitment manoeuvre is more likely to occur early in the course of acute respiratory failure than at later stages, when atelectasis may have become consolidated.1 However, individual patient response to a recruitment manoeuvre is difcult to predict. In a study on acute lung injury (ALI)/ARDS patients, potentially recruitable lung was assessed by CT-scan2 and the percentage of potentially recruitable lung (PRL%) was dened as the proportion of lung tissue in which aeration was restored when airway pressures were increased from 5 to 45 cmH2O. Patients in that study showed extremely variable lung recruitability, where patients with the highest recruitability had signicantly lower compliance, a lower PaO2/FIO2 ratio, a higher dead space fraction and higher mortality. PRL% also correlated to the severity of lung injury and the effect of PEEP. The drawback of that technique to assess

lung recruitability is that it requires CT, which limits its use due to safety reasons, including radiation and transportation. To simplify the concept of potentially recruitable lung, this study examines the possibility to assess the potentially recruitable lung volume (PRLV) using volumedependent compliance and measurements of lung volume changes using electric impedance tomography (EIT). This is a non-radiological imaging technique for the continuous assessment of lung volume changes at the bedside. Previous studies have shown that there is a close correlation between lung volume and impedance changes in a wide lung volume range.3 PRLV is dened as the difference between the open, fully recruited lung volume at 40 cmH2O (NRLV40) and the non-recruited lung volume extrapolated to the same airway pressure, based on the assumption that a volume delivered at the speed of a normal respiratory rate will not recruit the lung

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but just lead to further expansion of already open alveoli.46 The aim of the present pilot study was to assess whether it is possible to use this technique to determine lung recruitability and to set optimal PEEP in patients with ALI.

Lung mechanics
By inserting a pressure line through the endotracheal tube and positioning the distal tip at the end of the tube, tracheal pressure was measured continuously, using a conventional sensor for invasive pressure measurement. Alveolar pressure/volume (P/V) curves during ongoing ventilation were obtained using the dynostatic algorithm.9 Volume-dependent initial, middle and nal compliance of the breath were determined by analysis of the pressurevolume differences at 515% (Cini), 4555% (Cmid) and 8595% (Cn) of the Vt (Fig. 1).7,9 Conventional two-point compliance (Cconv) was calculated as the Vt divided by the difference between the end-inspiratory and the end-expiratory tracheal pressure.10,11

Patients and methods


The study was approved by the Human Ethics Committee of the University of Gothenburg, Sweden. Written informed consent was obtained from the next of kin to 16 ventilated patients with early ALI dened as a PaO2/FiO2 o300 mmHg at a PEEP of at least 5 cmH2O. Patients with chronic obstructive lung disease or heart failure were not included in the study.

Gas exchange End-expiratory lung volume (EELV)


EELV at baseline was determined using a modied nitrogen wash-out/wash-in procedure, in which the fraction of inspired oxygen (FiO2) was increased in one step by approximately 0.2, and then decreased in the same way, to achieve nitrogen wash-out and wash-in, respectively.7 Oxygen consumption and carbon dioxide production were measured continuously by indirect calorimetry (COVX-module, S/5, GE Healthcare, Helsinki, Finland). Mixed venous oxygen content was calculated by Ficks equation using blood gas measurements for arterial oxygen content, indirect calorimetry for oxygen consumption and cardiac output from oesophageal Doppler measurements (Cardio-Q, Deltex Medical Ltd, Chichester, West Sussex, UK).12 Shunt was calculated according to a standard formula.

EIT
A rubber belt, containing 16 electrodes, was placed around the thorax at the level of the fth intercostal space and connected to the EIT monitor (Dra ger/ GoeMFII, Lu beck, Germany). Small electrical currents (5 mA, 50 kHz) were applied in a rotating manner and the voltage differences between neighbouring electrode pairs were measured. A scan, displaying the ventilation-induced impedance changes, was obtained every 50 to 77 ms (13 20 Hz). The scan represents a 1520 cm thick slice of the thorax.8 The EIT end-expiratory signal was calibrated against measured EELV. Tidal volume-related impedance changes were calibrated against known lung volume changes by stepwise increasing tidal volume (Vt) in four steps of 100 ml each. The changes in end-expiratory impedance caused by changes in end-expiratory pressure were used for the calculation of changes in EELV above the baseline level measured by the nitrogen wash-in/wash-out methodology.

Study procedure
Patients were haemodynamically stable at start of the protocol, and to further minimize the risk for negative circulatory side effects, 0.5 l of colloid (hetastarch) was given. Haemodynamic data during the RM will be presented in a separate study (Lowhagen KLS, et al., Submitted). At baseline, patients were ventilated in volume control with a Vt of 6 ml/kg, an I:E ratio of 1 : 2, 10% end-inspiratory pause and PEEP of 6 cmH2O. With these settings, baseline measurements were performed and the EIT signal calibrated. Each patient was then subjected to a vital capacity manoeuvre (VICM) to a pressure of 40 cmH2O for 20 s repeated after a 40-s intermission with volume-controlled ventilation at PEEP 16 cmH2O. After the recruitment, a decremental PEEP trial was performed from 16 to 6 cmH2O in steps of 2 cmH2O, 2 min at each level.

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PRLV = Potentially recruitable lung volume XVOL40= Tidal volume extrapolated to 40 cmH O plateau pressure

V = Baseline tidal volume NRLV40 = Non-recruited lung at 40 cmH O EELV = Baseline end-expiratory lung volume

OLV40 = Open, fully recruited lung at 40 cmH O

800 ml
BL VICM

600 Cfin 400 Cmid 200 0 0 Vt Cini

n olatio extrap

XVOL40

cmH2O 10 20 30 40

Fig. 1. Schematic graph of the method for the graphical extrapolation of potentially recruitable lung volume (PRLV). The fully recruited open lung volume (OLV40) was dened as lung volume at the end of the second vital capacity manoeuvre at 40 cmH2O. The non-recruited lung volume (NRLV40) was dened as the end-expiratory lung volume at baseline plus a volume (XVOL40). This volume XVOL40 consists of the tidal volume plus a volume determined by graphical extrapolation, to a pressure of 40 cmH2O, of the upper part of the alveolar P/V-curve of a tidal breath. The PRLV was dened as OLV40 minus NRLV40. Three alveolar P/V-curves at baseline were used for the extrapolation.

PRLV
Determination of PRLV in the current study is based on data collected from EIT, EELV measurements and tracheal pressure to obtain dynostatic alveolar P/V-curves.9 Lung volume at the end of the second VICM, at 40 cmH2O, was regarded as the fully recruited, open lung volume (OLV40, Fig. 1). The non-recruited lung volume at the same pressure 40 cmH2O (NRLV40) was dened as the volume of the lung that has not been subjected to a VICM. This volume was calculated as baseline EELV at PEEP of 6 cmH2O, plus the tidal volume plus a volume generated by graphical extrapolation of the upper part of the alveolar P/V-curve, above the tidal volume, to a pressure of 40 cmH2O (XVOL40) (Fig. 1). All graphical extrapolations were performed by the same person, and the average value from P/V-curves of three different breaths at each PEEP level was used for further calculations. PRLV was dened as OLV40 minus NRLV40. PRLV expressed in percent of OLV40 was dened as PRLV%, which was calculated at base-

line and at all PEEP levels during the decremental PEEP trial. To enable an automatic procedure for determining potential recruitability, a mathematical extrapolation was also performed using a logarithmic s trend software (Excel , Microsoft Inc., Redmond, WA, USA). Logarithmic extrapolation was used based on previous studies on the Dynostatic P/V curve, which have shown the best t using a logarithmic function.9

Optimal PEEP
Post hoc analysis of optimal PEEP during the decremental PEEP trial was performed. Optimal PEEP was arbitrarily dened as the lowest PEEP level at which PRLV% was 10%, (PRLV%410% indicating possible derecruitment. If such low PRLV% as o10% was not reached, the PEEP level with the lowest PRLV% was used. Optimal PEEP was also dened as the PEEP level with the highest compliance during the decremental PEEP trial. If

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compliance was equally high at two different PEEP levels, the lowest of the two PEEP levels was selected. The maximum percentage increase (or for shunt; decrease) was registered for EELV, Cconv, Cini, PaO2/FiO2 and shunt.

Statistics
Values are presented as mean standard deviation. The coefcient of variation for the calculation of NRLV40 was calculated. The correlation between graphical and mathematical extrapolation to determine non-recruited lung volume was assessed using linear regression analysis. In a post hoc analysis, patients were divided by the median into a low and a high PRLV group, and differences between the groups were assessed using unpaired Students t-test. P-values o0.05 were considered statistically signicant.

Results
The mean age for the 16 patients (12 males, four females) in this study was 62 9 years. Patient characteristics are provided in Table 1. Patients had been on mechanical ventilation for 41 21 h (range 1294 h) before the study. The PaO2/FiO2 ratio measured at baseline with PEEP 6 cmH2O was 181 71 mm Hg.

PRLV
The coefcient of variation for the graphical extrapolation was 6%. There was a good correlation between the graphical and the mathematical extrapolation (R2 5 0.92). All results presented are obtained from the graphical extrapolations. PRLV expressed in percent of OLV40 at baseline (PRLV%) was 26 11% (range 1147%), corresponding to a PRLV value of 786 556 ml (range 2262530 ml). When dividing the patients by the median PRLV% value, into a high PRLV and a low PRLV group, the average PRLV% was 35 7% in the high and 17 6% in the low PRLV group (Table 1). At baseline, PEEP 6 cmH2O, conventional twopoint compliance was signicantly lower in the high PRLV group, 29 9 ml/cmH2O, than in the low PRLV group, 40 6 ml/cmH2O. The patients in the high PRLV group also had signicantly lower volume-dependent initial compliance, 37 11 ml/cmH2O, compared with the low PRLV

group, 58 18 ml/cmH2O. While the OLV40, at the end of the second VICM, was similar in the two groups, there was a clear, although non-signicant, tendency towards a lower EELV at baseline in the high PRLV group. The fraction of EELV at baseline in relation to OLV40 was signicantly lower in the high PRLV group compared with the low PRLV group. Hours of mechanical ventilation before the study differed between the high PRLV group, 52 20 h, and the low PRLV group, 30 16 h (Po0.05). When compared with the low PRLV group, patients in the high PRLV group had a signicantly higher maximal increase in EELV (199 31 vs. 168 19%, Po0.05) and conventional compliance from 29 9 to 40 10 ml/cmH2O (140 19%) vs. from 40 6 to 40 10 ml/cmH2O (112 16%), Po0.01 during the decremental PEEP trial after the VICM. Similar trends were observed in the PaO2/FiO2 ratio (155 64 vs. 117 19%), shunt ( 34 20 vs. 23 14%) and volume-dependent initial compliance (1111 120 vs. 49 60%) (NS). Figure 2 shows typical examples of alveolar P/V curves and the extrapolated volume and illustrates PRLV for one patient with high and one patient with low PRLV, at the different PEEP levels. Optimal PEEP, whether it was dened on the basis of PRLV or compliance, was signicantly higher in the high PRLV group than the low PRLV group (Table 1). The lowest and highest quartile of patients regarding PRLV% are displayed in Fig. 3, also displaying the difference in optimal PEEP between high and low PRLV.

Discussion
This study presents a new bedside method to determine PRLV, which may be able to identify patients who are most or least likely to benet from a recruitment manoeuvre and high PEEP. The study shows that, using EIT, it is possible to assess PRLV by determining OLV, using a vital capacity recruitment manoeuvre, and subtract the non-recruited lung volume given by extrapolation of the alveolar P/V curve of the tidal volume up to the same airway pressure. Applying this method in a group of patients with early ALI and/or ARDS, we observed a large variation between the patients in PRLV. We used the pressure of 40 cmH2O for dening fully recruited lung volume, which was dened as

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Table 1
PaO2/FiO2 BL (mmHg) Shunt BL Ventilat (%) time (hours) Compl ini EELV BL BL (ml) (ml/cmH2O) OLV40 (ml) PRLV (ml) Compl conv BL (ml/cmH2O) EELVBL/ OLV40 (%) Optimal PEEP PRLV (cmH2O) 25 29 34 29 31 42 37 35 33 5 0.03 42 9 3477 3269 2308 2759 2949 3479 2867 2135 850 787 529 397 422 409 318 226 50 35 39 39 34 58 34 45 16 16 14 10 16 16 10 10 14 3 0.002 92 12 10 10 10 8 6 6 6 Optimal PEEP Cconv (cmH2O) 16 10 8 10 12 16 10 10 12 3 0.02 82 6 12 10 8 8 6 8 8

Patients characteristics, gas exchange and lung mechanic parameters in patients with high and low PRLV.

Cause of lung injury

PRLV%

High PRLV% Pneumonia Other Trauma Aspiration Sepsis Other Sepsis Pneumonia Mean high PRLV% P-value Mean low PRLV% Low PRLV% Aspiration Sepsis Other Sepsis Sepsis Sepsis Pneumonia Sepsis 116 258 280 200 129 247 144 83 182 74 0.08 173 73 292 165 64 237 131 223 128 141 13 22 46 18 35 22 24 23 48 23 35 13 50 13 42 12 37 43 35 37 45 47 45 29 42 43 38 75 78 67 77 42 1742 1131 889 1080 997 2023 970 954 36 10 17 13 28 19 30 31 23 10 0.64 25 10 55 54 94 59 49 38 28 40 52 20 0.03 30 16 33 29 22 42 27 14 29 37 29 9 0.01 40 6 45 24 43 51 30 24 32 47 37 11 0.01 58 18 1357 998 874 772 798 815 762 1019 924 201 0.09 1223 420 5416 3428 2556 2695 2566 1953 2061 2887 2945 1100 0.93 2905 501

47 43 36 34 31 30 30 29 35 7 o0.001 17 6

2530 1466 908 912 802 587 617 824 1081 645 0.03 492 220

24 24 23 14 14 12 11 11

A new non-radiological method to assess potential lung recruitability

Mean values are given SD. P-values for comparisons between high and low PRLV groups are shown. PRLV%, percentage potentially recruitable lung volume; BL, baseline; Compl conv, conventional two-point compliance; Compl ini, volume-dependent initial compliance; EELV, end-expiratory lung volume; OLV40, open lung volume at 40 cmH2O; PRLV, potentially recruitable lung volume.

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OLV PRLV Patient with low PRLV%

OLV Patient with high PRLV%

PRLV

Fig. 2. Typical examples of alveolar P/V curves, the upper panel displaying a patient with a low potentially recruitable lung volume (PRLV), and the lower panel showing a patient with high PRLV. Both panels demonstrate P/V curves at baseline and after the vital capacity manoeuvre (VICM, indicated by a grey vertical line) at each PEEP level during the decremental PEEP trial. Each P/V curve consists of a blue and a red part, the blue being the actual curve measured and the red the extrapolated part of the curve. The hatched line indicates the open lung volume (OLV40). In the patient with low PRLV%, graphic extrapolation at PEEP 6 cmH2O (before the VICM) reaches a point fairly close to the OLV40, indicating a PRLV% of around only 10%. At PEEP 16, following the VICM, the extrapolated P/V-curve nearly reaches the OLV40. Note, however, how the P/V curve is depressed at high PEEP, indicating a decline in compliance. During the decremental PEEP trial, PRLV increases only slightly and optimal PEEP (arrow) occurred at 8 cmH2O. In contrast, in the patient with high PRLV% (lower panel), there is a marked decrease in PRLV following the vital capacity manoeuvre and an increase in compliance can be seen at high PEEP. This is followed by rapid derecruitment and a large increase in PRLV during the decremental PEEP trial already at fairly high PEEP levels, with optimal PEEP dened as 14 cmH2O. It could also be noted that there seems to be a lower inection point (LIP) at baseline in the high PRLV patient. This LIP disappears after the VICM but then reappears again at PEEP 6 cmH2O.

the EELV measured using a N2 wash-out/wash-in technique plus the calibrated EIT volume above baseline EELV, at that pressure. The NRLV40 was obtained by graphic extrapolation of the upper part of the dynostatic P/V curve (Fig. 1). This extrapolated lung volume is an imaginary volume based on the assumption that a volume delivered at the speed of a normal respiratory rate will not recruit the lung but just lead to further expansion of already open alveoli.4,5 In future studies, this assumption will be further validated. It should be added that other methods to assess lung volume changes could be used, instead of EIT, such as spirometry or respiratory inductive plethysmography. Also, it has been shown that compliance

during a slow static P/V curve manoeuvre is much higher than during a fast delivery of a normal tidal volume in the same pressure range.6,13 The difference between fully recruited lung volume and the non-recruited lung volume at the same pressure constitutes the PRLV and the proportion of this in relation to the fully recruited lung volume is the PRLV%, which should correspond to the potentially recruitable lung described by Gattinoni et al.2 We chose to perform the extrapolation of the dynostatic P/V curve graphically. Post hoc, we also performed a mathematical extrapolation using a logarithmic method, and on comparing the two methods, there was a good correlation between the results. Thus, in the future, it should be possible

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OLV40 EELV NRLV40 ml 6000 Lung volume 4000 2000 0 High PRLV 6000 4000 2000 0 ml Low PRLV

BL

16

14

12

10

BL

16

14

12

10

6000 4000 2000 0 BL 6000 4000 2000 0 16 14 12 10 8 6

6000 4000 2000 0

BL

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6000 4000 2000 0 BL 16 14 12 10 8 6 6000 4000 2000 PEEP (cmH2O) BL 16 14 12 10 8 6 0 PEEP (cmH2O) BL 16 14 12 10 8 6 BL 16 14 12 10 8 6

6000 4000 2000 0

Fig. 3. The highest (four patients) and lowest (four patients) quartiles of patients according to the percentage of potentially recruitable lung volume (PRLV, indicated by shaded area). Optimal PEEP is indicated by an arrow. There is almost no PRLV at any PEEP level in the low PRLV group, which indicates that the patients in this group would benet neither from a recruitment manoeuvre nor from high PEEP levels. In the high PRLV group, for two of the patients, there remains a PRLV even at the highest PEEP immediately after the end of the VICM. Irrespective of low or high PRLV%, the EELV is always the highest at the highest PEEP and decreases stepwise, linearly from a peak value at PEEP 16 cmH2O after the RM. Thus, optimal PEEP cannot be set based on EELV.

to obtain the PRLV values on-line, using the appropriate software to supply a reproducible extrapolation. Previously, Gattinoni and colleagues studied ALI/ARDS patients who underwent a whole lung CT during breath-holding sessions at 5, 15 and 45 cmH2O. The percentage of potentially recruita-

ble lung (tissue) (dened as the proportional difference in non-aerated lung on a CT scan at 5 vs. 45 cmH2O) was determined. In the present study, instead of assessing potentially recruitable lung tissue, we determined PRLV, and in agreement with Gattinoni and colleagues, we found a marked variation in recruitability between

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different patients with ALI/ARDS. Thus, introducing the concept of PRLV, we attempted to develop a surrogate method, where the use of CT scan, with its obvious drawbacks, could possibly be substituted. EIT, a radiation-free technique, is a poor method for identifying non-aerated lung, but a good method for identifying aerated lung. It is a bedside imaging method and is suitable for continuous measurements, and its rubber electrode belt can be left on for extended periods of time. The advantage of our method is that PRLV is not only measured at one time point, but instead, we are able to obtain the percentage of recruitable lung volume at different PEEP levels and also, importantly, PRLV can be determined bedside repeatedly over time. It has been claimed that very high pressures are needed to recruit the lung, in some patients up to 60 cmH2O.14 Recruitment manoeuvres using high airway pressures may have a negative impact on haemodynamics.1,15 In the present study, for safety reasons, we used 40 cmH2O to dene an open, fully recruited lung volume. However, the method presented in this study is not limited to the chosen pressure it is possible to use a higher recruitment pressure and to extrapolate the dynostatic P/V curve to that pressure level. The described method requires the use of a pressure line (thin plastic catheter) inserted through the endotracheal tube, with its tip positioned at the end of the tube, for measurements of tracheal pressure. This equipment is already available in a commercial ventilator. Although extrapolation of a curve always involves some uncertainty, the extrapolations made in this study were repeated for three breaths at each PEEP level, and there was a very good agreement between the values obtained at each level. Furthermore, when compared with logarithmic extrapolation, which is performer independent, there was a close correlation with those obtained graphically. It should be noted that this study is restricted to measuring aerated lung areas. Consequently, we do not measure consolidated lung, as opposed to using CT, where these parts of the lungs can be visualized and measured.3,16 The optimal time point to measure lung recruitability can be debated. In the study by Gattinoni et al.2 the measurements were performed when patients had been on the ventilator for 5 days. We advocate an early assessment of PRLV, as patients are more apt to respond to recruitment manoeuvres as well as to high PEEP in the early stages of the

disease.1 In the present study, we measured PRLV after a mean of 2 days of mechanical ventilation. We believe that in addition to measuring early, it is also important to repeat measurements as ALI/ ARDS has a dynamic course of disease.17 This can easily be done using our technique. The results of this study underline the importance of setting PEEP depending on the degree of lung recruitability, which has been shown previously by Gattinoni. We dened optimal PEEP based on PRLV, during a decremental PEEP trial. Thus, a full PEEP trial is displayed in Fig. 2, where overination is obvious at high PEEP levels in a low PRLV patient. Moreover, a lower inection point, as a sign of cyclic opening and closing at low PEEP levels, is seen in a high PRLV patient. These ndings indicate the importance of balancing PEEP and tidal volume appropriately.18 This is further emphasized when dividing the patients into two groups according to PRLV a high and a low PRLV group where we found that the high PRLV group had considerably higher optimal PEEP than the low PRLV group. It is possible that high PEEP in patients with low PRLV could be harmful, causing overdistension (Fig. 2), while a lower inection point can be observed at low PEEP levels in patients with a high degree of recruitability (Fig. 2). As pointed out earlier by Gattinoni et al.,2 the lack of titration of PEEP in relation to the degree of recruitability could be one factor explaining why studies on high vs. low PEEP have failed to show differences in outcome.19,20 The patients in these studies probably did include both patients with a high and a low degree of recruitability. Perhaps it is not only a question of choosing between high or low PEEP, but instead that PEEP should be titrated during the course of ALI/ARDS, and for the same patient, optimal PEEP could be high in the beginning and lower later on. In this post hoc study, we found, somewhat surprisingly, a difference in ventilator time at baseline between the high and the low PRLV group. This could possibly be explained by the lung condition slowly becoming worse, i.e. increasing lung collapse during the course of the disease. Still the ventilator time is fairly short compared with that in the study by Gattinoni. We assume that in our study with ventilator times less than 3 days, it is still possible to recruit lungs as consolidation has not yet occurred. Further studies of this methodology should include measurement of potential recruitability within hours of the patient being on the ventilator.

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In contrast to the study by Gattinoni performed in patients ventilated for a longer period (5 days), we did not observe any difference in PaO2/FiO2, shunt or outcome between patients in the high and the low PRLV group. A much larger study is needed to address this question.

6.

7.

Conclusion
In this pilot study, we propose a new non-invasive radiation-free bedside method to assess lung recruitability and to set optimal PEEP in ventilated ALI/ARDS patients. In accordance with the results from Gattinoni and colleagues, it appears that patients with a high PRLV show a greater response to a recruitment manoeuvre and could benet from higher PEEP than patients with low recruitability. Still, further studies are needed using this technique as well as validating it against CT techniques. Quantication of PRLV may offer a possibility to select patients who need high, medium and low PEEP. In addition, this technique could be used daily to adjust the ventilation and PEEP settings throughout the course of the disease.

8.

9.

10.

11.

12.

Acknowledgements
This study was supported by grants from the Medical Faculty of University of Gothenburg and the Gothenburg Medical Society. The EIT equipment was supplied by Dra ger Medical AG, Germany, and the authors are grateful for valuable advice from Mr Eckhard Teschner, at Dra ger Medical.

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14.

References
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Address: whagen Dr Karin Lo Department of Anaesthesia and Intensive Care Medicine Sahlgrenska University Hospital 41345 Go teborg Sweden e-mail: karin.lowhagen@vgregion.se

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