Protective ventilation in experimental acute respiratory distress syndrome after ventilator-induced lung injury: a randomized controlled trial L. Uttman,

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Protective ventilation in experimental acute respiratory distress syndrome after ventilator-induced lung injury: a randomized controlled trial L. Uttman, U. Bitzén, E. De Robertis, J. Enoksson, L. Johansson, B. Jonson British Journal of Anaesthesia Volume 109, Issue 4, Pages 584-594 (October 2012) DOI: 10.1093/bja/aes230 Copyright © 2012 The Author(s) Terms and Conditions

Fig 1 Inspiratory Pel/V curves recorded from PEEP 15 to 0 cm H2O and expiratory Pel/V curves recorded from 50 cm H2O; average in each group at 0, 16, and 24 h. Inspiratory curves showed significant differences related to starting pressure over the full pressure range apart from LP at 0 h and in HP at 24 h (two-way analysis of variance). British Journal of Anaesthesia 2012 109, 584-594DOI: (10.1093/bja/aes230) Copyright © 2012 The Author(s) Terms and Conditions

Fig 2 Upper panels: average inspiratory Pel/V curves recorded from zero PEEP in the three groups. Middle panels: average inspiratory Pel/V curves recorded from PEEP 15 cm H2O. Lower panels: average expiratory Pel/V curves recorded from 50 cm H2O. Volume trends over time in the direction of the arrows were significant over the indicated pressure ranges. British Journal of Anaesthesia 2012 109, 584-594DOI: (10.1093/bja/aes230) Copyright © 2012 The Author(s) Terms and Conditions

Fig 3 Haemodynamics and gas exchange during the study. GOAL differed from the LP and HP as indicated by asterisks in blue and green colours, respectively. Data are expressed as mean and sd. British Journal of Anaesthesia 2012 109, 584-594DOI: (10.1093/bja/aes230) Copyright © 2012 The Author(s) Terms and Conditions

Fig 4 Lung injury score in individual pigs at the end of the study. British Journal of Anaesthesia 2012 109, 584-594DOI: (10.1093/bja/aes230) Copyright © 2012 The Author(s) Terms and Conditions

Fig 5 Realistic distributions of opening and closing pressures of lung units in ARDS. Arrows illustrate the range PEEPTOT to PPLAT under different ventilation regimes. Arrow 1 refers to obsolete high VT/low PEEP ventilation at which most lung units undergo RECOREX, while high PPLAT causes barotrauma. Arrow 2 represents moderate VT/high PEEP ventilation. Only units with high closing pressure undergo RECOREX, but barotrauma remains important. Arrow 3 illustrates moderate VT/low PEEPTOT. Low PPLAT prevents barotrauma, but many lung units collapsing during expiration undergo RECOREX. Arrow 4 illustrates very low VT/high PEEP ventilation. Low PPLAT prevents barotrauma. Only those units with particularly high closing pressures represented by the pink area will close. If these units also have high opening pressures (pink area), they will remain collapsed throughout the breath so as to fully prevent RECOREX. British Journal of Anaesthesia 2012 109, 584-594DOI: (10.1093/bja/aes230) Copyright © 2012 The Author(s) Terms and Conditions