Intestinal effects of lung recruitment maneuvers

Abstract: Background and aims: Lung recruitment maneuvers (brief episodes of high airway pressure) are a modern treatment alternative to achieve open lung conditions under mechanical ventilation of patients with acute lung injury. It is well known that positive pressure ventilation with high airway pressures cause negative circulatory effects, and that the effects on regional vascular beds can be even more pronounced than the systemic effects. Hypoperfusion of the mesenteric vascular bed can lead to tissue ischemia and local inflammation. This intestinal inflammation has been associated with subsequent development of multiple organ dysfunction syndrome, a syndrome that still carries a high mortality and is a leading cause of death for intensive care patients. The aim of this thesis was therefore to investigate whether lung recruitment maneuvers would cause negative effects on mesenteric circulation, oxygenation or metabolism.Methods and results: In an initial study on ten patients with acute lung injury, we could demonstrate a trend towards a decreased gastric mucosal perfusion during three repeated lung recruitment maneuvers. To more closely examine this finding, we set up an oleic acid lung injury model in pigs, and in our second study we established that this model was devoid of inherent intestinal effects and was adequate for subsequent studies of intestinal effects of lung recrutiment maneuvers. In the acute lung injury model, we also tested the effect of an infusion of a vasodilating agent concurrent with the recruitment maneuvers, the hypothesis being that a vasodilating agent would prevent intestinal vasoconstriction and hypoperfusion. We could show that three repeated lung recruitment maneuvers induced short term negative effects on mesenteric oxygenation and metabolism, but that these findings were transient and short lasting. Further, the effects of prostacyclin were minor and opposing. These findings of relative little impact on the intestines of lung recruitment maneuvers, lead us to investigate the hypothesis that repeated recruitment maneuvers maybe could elicite a protective intestinal preconditioning response, a phenomenon previously described both in the rat and in the dog. However, in our fourth study, using both classical ischemic preconditioning with brief periods of intestinal ischemia or repeated lung recrutiment maneuvers, we could not demonstrate the phenomenon of intestinal preconditioning in the pig.Conclusions: We conclude, that from a mesenteric point of view, lung recruitment maneuvers are safe, and only induce transient and short lasting negative effects. We also conclude that the cause of the minor effects of lung recruitment maneuvers is not dependent on intestinal preconditioning.