Asymmetrical Lung Injury: Management and Outcome

Luca Bastia; Hadrien Rozé; Laurent J. Brochard

doi:10.1055/s-0042-1744303

Seminars in Respiratory and Critical Care Medicine, Table of Contents

Semin Respir Crit Care Med 2022; 43(03): 369-378
DOI: 10.1055/s-0042-1744303

Review Article

Asymmetrical Lung Injury: Management and Outcome

Luca Bastia

¹Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

²Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada

³Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada

,

Hadrien Rozé

⁴Thoracic Surgery and Lung Transplant Unit, Department of Anesthesiology and Critical Care, Bordeaux University Hospital, Haut Leveque Hospital, Pessac, France

⁵Centre de Recherche Cardio Thoracique INSERM 1045, Pessac, France

,

Laurent J. Brochard

²Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada

³Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada

⁶Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Canada

› Author Affiliations

Abstract

Among mechanically ventilated patients, asymmetrical lung injury is probably extremely frequent in the intensive care unit but the lack of standardized measurements does not allow to describe any prevalence among mechanically ventilated patients. Many past studies have focused only on unilateral injury and have mostly described the effect of lateral positioning. The good lung put downward might receive more perfusion while the sick lung placed upward receive more ventilation than supine. This usually results in better oxygenation but can also promote atelectasis in the healthy lung and no consensus has emerged on the clinical indication of this posture. Recently, electrical impedance tomography (EIT) has allowed for the first time to precisely describe the distribution of ventilation in each lung and to better study asymmetrical lung injury. At low positive-end-expiratory pressure (PEEP), a very heterogeneous ventilation exists between the two lungs and the initial increase in PEEP first helps to recruit the sick lung and protect the healthier lung. However, further increasing PEEP distends the less injured lung and must be avoided. The right level can be found using EIT and transpulmonary pressure. In addition, EIT can show that in the two lungs, airway closure is present but with very different airway opening pressures (AOPs) which cannot be identified on a global assessment. This may suggest a very different PEEP level than on a global assessment. Lastly, epidemiological studies suggest that in hypoxemic patients, the number of quadrants involved has a strong prognostic value. The number of quadrants is more important than the location of the unilateral or bilateral nature of the involvement for the prognosis, and hypoxemic patients with unilateral lung injury should probably be considered as requiring lung protective ventilation as classical acute respiratory distress syndrome.

Keywords

acute respiratory failure - pneumonia - mechanical ventilation - acute respiratory distress syndrome - respiratory mechanics - esophageal pressure

Full Text

References

References
1 Kaneko K, Milic-Emili J, Dolovich MB, Dawson A, Bates DV. Regional distribution of ventilation and perfusion as a function of body position. J Appl Physiol 1966; 21 (03) 767-777
2 Remolina C, Khan AU, Santiago TV, Edelman NH. Positional hypoxemia in unilateral lung disease. N Engl J Med 1981; 304 (09) 523-525
3 Rivara D, Artucio H, Arcos J, Hiriart C. Positional hypoxemia during artificial ventilation. Crit Care Med 1984; 12 (05) 436-438
4 Zack MB, Pontoppidan H, Kazemi H. The effect of lateral positions on gas exchange in pulmonary disease. A prospective evaluation. Am Rev Respir Dis 1974; 110 (01) 49-55
5 Dreyfuss D, Djedaini K, Lanore JJ, Mier L, Froidevaux R, Coste F. A comparative study of the effects of almitrine bismesylate and lateral position during unilateral bacterial pneumonia with severe hypoxemia. Am Rev Respir Dis 1992; 146 (02) 295-299
6 Ibañez J, Raurich JM, Abizanda R, Claramonte R, Ibañez P, Bergada J. The effect of lateral positions on gas exchange in patients with unilateral lung disease during mechanical ventilation. Intensive Care Med 1981; 7 (05) 231-234
7 Gillespie DJ, Rehder K. Body position and ventilation-perfusion relationships in unilateral pulmonary disease. Chest 1987; 91 (01) 75-79
8 Dhainaut JF, Bons J, Bricard C, Monsallier JF. Improved oxygenation in patients with extensive unilateral pneumonia using the lateral decubitus position. Thorax 1980; 35 (10) 792-793
9 Thomas PJ, Paratz JD. Is there evidence to support the use of lateral positioning in intensive care? A systematic review. Anaesth Intensive Care 2007; 35 (02) 239-255
10 Hewitt N, Bucknall T, Faraone NM. Lateral positioning for critically ill adult patients. Cochrane Database Syst Rev 2016; 2016 (05) CD007205
11 Meli A, Barbeta Viñas E, Battaglini D. et al. Lateral position during severe mono-lateral pneumonia: an experimental study. Sci Rep 2020; 10 (01) 19372
12 Roldán R, Rodriguez S, Barriga F. et al. Sequential lateral positioning as a new lung recruitment maneuver: an exploratory study in early mechanically ventilated Covid-19 ARDS patients. Ann Intensive Care 2021; 12 (01) 13
13 Dreyfuss D, Soler P, Basset G, Saumon G. High inflation pressure pulmonary edema. Respective effects of high airway pressure, high tidal volume, and positive end-expiratory pressure. Am Rev Respir Dis 1988; 137 (05) 1159-1164
14 Amigoni M, Bellani G, Zambelli V. et al. Unilateral acid aspiration augments the effects of ventilator lung injury in the contralateral lung. Anesthesiology 2013; 119 (03) 642-651
15 Mink SN, Light RB, Wood LD. Effect of pneumococcal lobar pneumonia on canine lung mechanics. J Appl Physiol 1981; 50 (02) 283-291
16 Blanch L, Murias G, Nahum A. Lung recruitment in unilateral lung disease. Minerva Anestesiol 2002; 68 (05) 351-355
17 Glass DD, Tonnesen AS, Gabel JC, Arens JF. Therapy of unilateral pulmonary insufficiency with a double lumen endotracheal tube. Crit Care Med 1976; 4 (06) 323-326
18 Powner DJ, Eross B, Grenvik A. Differential lung ventilation with PEEP in the treatment of unilateral pneumonia. Crit Care Med 1977; 5 (04) 170-172
19 Cinnella G, Dambrosio M, Brienza N. et al. Independent lung ventilation in patients with unilateral pulmonary contusion. Monitoring with compliance and EtCO(2). Intensive Care Med 2001; 27 (12) 1860-1867
20 Rivara D, Bourgain JL, Rieuf P, Harf A, Lemaire F. Differential ventilation in unilateral lung disease: effects on respiratory mechanics and gas exchange. Intensive Care Med 1979; 5 (04) 189-191
21 Hedenstierna G, Baehrendtz S, Klingstedt C. et al. Ventilation and perfusion of each lung during differential ventilation with selective PEEP. Anesthesiology 1984; 61 (04) 369-376
22 Carlon GC, Kahn R, Howland WS, Baron R, Ramaker J. Acute life-threatening ventilation-perfusion inequality: an indication for independent lung ventilation. Crit Care Med 1978; 6 (06) 380-383
23 East IV TD, Pace NL, Westenskow DR, Lund K. Differential lung ventilation with unilateral PEEP following unilateral hydrochloric acid aspiration in the dog. Acta Anaesthesiol Scand 1983; 27 (05) 356-360
24 Berg S, Bittner EA, Berra L, Kacmarek RM, Sonny A. Independent lung ventilation: implementation strategies and review of literature. World J Crit Care Med 2019; 8 (04) 49-58
25 Anantham D, Jagadesan R, Tiew PE. Clinical review: independent lung ventilation in critical care. Crit Care 2005; 9 (06) 594-600
26 Blanch L, Van der Kloot TE, Youngblood AM. et al. Application of tracheal gas insufflation to acute unilateral lung injury in an experimental model. Am J Respir Crit Care Med 2001; 164 (04) 642-647
27 Blanch L, Van der Kloot TE, Youngblood AM. et al. Selective tracheal gas insufflation during partial liquid ventilation improves lung function in an animal model of unilateral acute lung injury. Crit Care Med 2001; 29 (12) 2251-2257
28 Zhu G, Shaffer TH, Wolfson MR. Continuous tracheal gas insufflation during partial liquid ventilation in juvenile rabbits with acute lung injury. J Appl Physiol (1985) 2004; 96 (04) 1415-1424
29 Pham T, Pesenti A, Bellani G. et al. LUNG SAFE Investigators and the European Society of Intensive Care Medicine Trials Group. Outcome of acute hypoxaemic respiratory failure: insights from the LUNG SAFE Study. Eur Respir J 2021; 57 (06) 2003317
30 Bastia L, Engelberts D, Osada K. et al. Role of positive end-expiratory pressure and regional transpulmonary pressure in asymmetrical lung injury. Am J Respir Crit Care Med 2021; 203 (08) 969-976
31 Puybasset L, Cluzel P, Chao N, Slutsky AS, Coriat P, Rouby JJ. The CT Scan ARDS Study Group. A computed tomography scan assessment of regional lung volume in acute lung injury. Am J Respir Crit Care Med 1998; 158 (5 pt. 1): 1644-1655
32 Kim MJ, Hwang HJ, Song HH. A randomized trial on the effects of body positions on lung function with acute respiratory failure patients. Int J Nurs Stud 2002; 39 (05) 549-555
33 Gattinoni L, Caironi P, Cressoni M. et al. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med 2006; 354 (17) 1775-1786
34 Constantin JM, Grasso S, Chanques G. et al. Lung morphology predicts response to recruitment maneuver in patients with acute respiratory distress syndrome. Crit Care Med 2010; 38 (04) 1108-1117
35 Reske AW, Rau A, Reske AP. et al. Extrapolation in the analysis of lung aeration by computed tomography: a validation study. Crit Care 2011; 15 (06) R279
36 Siegel JH, Stoklosa JC, Borg U. et al. Quantification of asymmetric lung pathophysiology as a guide to the use of simultaneous independent lung ventilation in posttraumatic and septic adult respiratory distress syndrome. Ann Surg 1985; 202 (04) 425-439
37 Miller GW, Mugler III JP, Sá RC, Altes TA, Prisk GK, Hopkins SR. Advances in functional and structural imaging of the human lung using proton MRI. NMR Biomed 2014; 27 (12) 1542-1556
38 Jain S, Williams DJ, Arnold SR. et al. CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among U.S. children. N Engl J Med 2015; 372 (09) 835-845
39 Upchurch CP, Grijalva CG, Wunderink RG. et al. Community-acquired pneumonia visualized on CT scans but not chest radiographs: pathogens, severity, and clinical outcomes. Chest 2018; 153 (03) 601-610
40 Dillon DG, Rodriguez RM. Screening performance of the chest X-ray in adult blunt trauma evaluation: Is it effective and what does it miss?. Am J Emerg Med 2021; 49: 310-314
41 Kea B, Gamarallage R, Vairamuthu H. et al. What is the clinical significance of chest CT when the chest x-ray result is normal in patients with blunt trauma?. Am J Emerg Med 2013; 31 (08) 1268-1273
42 Miller PR, Croce MA, Bee TK. et al. ARDS after pulmonary contusion: accurate measurement of contusion volume identifies high-risk patients. J Trauma 2001; 51 (02) 223-228 , discussion 229–230
43 Bouhemad B, Brisson H, Le-Guen M, Arbelot C, Lu Q, Rouby JJ. Bedside ultrasound assessment of positive end-expiratory pressure-induced lung recruitment. Am J Respir Crit Care Med 2011; 183 (03) 341-347
44 Lichtenstein D, Mezière GA. Utility of lung sonography in acute respiratory failure. Chest 2009; 135 (03) 884-885
45 Riviello ED, Kiviri W, Twagirumugabe T. et al. Hospital incidence and outcomes of the acute respiratory distress syndrome using the kigali modification of the Berlin Definition. Am J Respir Crit Care Med 2016; 193 (01) 52-59
46 Rozé H, Boisselier C, Bonnardel E. et al. Electrical impedance tomography to detect airway closure heterogeneity in asymmetrical acute respiratory distress syndrome. Am J Respir Crit Care Med 2021; 203 (04) 511-515
47 Borges JB, Cronin JN, Crockett DC, Hedenstierna G, Larsson A, Formenti F. Real-time effects of PEEP and tidal volume on regional ventilation and perfusion in experimental lung injury. Intensive Care Med Exp 2020; 8 (01) 10
48 Spinelli E, Kircher M, Stender B. et al. Unmatched ventilation and perfusion measured by electrical impedance tomography predicts the outcome of ARDS. Crit Care 2021; 25 (01) 192
49 Ouwens JP, van der Bij W, van der Mark TW. et al. The value of ventilation scintigraphy after single lung transplantation. J Heart Lung Transplant 2004; 23 (01) 115-121
50 Gattinoni L, Pesenti A, Avalli L, Rossi F, Bombino M. Pressure-volume curve of total respiratory system in acute respiratory failure. Computed tomographic scan study. Am Rev Respir Dis 1987; 136 (03) 730-736
51 Raghavendran K, Nemzek J, Napolitano LM, Knight PR. Aspiration-induced lung injury. Crit Care Med 2011; 39 (04) 818-826
52 Zingg SW, Millar DA, Goodman MD, Pritts TA, Janowak CF. The association between pulmonary contusion severity and respiratory failure. Respir Care 2021; 66 (11) 1665-1672
53 Chacon RA, Corris PA, Dark JH, Gibson GJ. Comparison of the functional results of single lung transplantation for pulmonary fibrosis and chronic airway obstruction. Thorax 1998; 53 (01) 43-49
54 Lee JC, Christie JD, Keshavjee S. Primary graft dysfunction: definition, risk factors, short- and long-term outcomes. Semin Respir Crit Care Med 2010; 31 (02) 161-171
55 Schaffer JM, Singh SK, Reitz BA, Zamanian RT, Mallidi HR. Single- vs double-lung transplantation in patients with chronic obstructive pulmonary disease and idiopathic pulmonary fibrosis since the implementation of lung allocation based on medical need. JAMA 2015; 313 (09) 936-948
56 Rodrigues AC, Moreira LF, de Souza CL, Pettersen PC, Saldiva PH, Zin WA. Effects of thoracotomy on respiratory system, lung, and chest wall mechanics. Chest 1993; 104 (06) 1882-1886
57 Leftwich E, Witorsch RJ, Witorsch P. Positive end-expiratory pressure in refractory hypoxemia. A critical evaluation. Ann Intern Med 1973; 79 (02) 187-193
58 Çoruh B, Luks AM. Positive end-expiratory pressure. When more may not be better. Ann Am Thorac Soc 2014; 11 (08) 1327-1331
59 Kanarek DJ, Shannon DC. Adverse effect of positive end-expiratory pressure on pulmonary perfusion and arterial oxygenation. Am Rev Respir Dis 1975; 112 (03) 457-459
60 Blanch L, Roussos C, Brotherton S, Michel RP, Angle MR. Effect of tidal volume and PEEP in ethchlorvynol-induced asymmetric lung injury. J Appl Physiol (1985) 1992; 73 (01) 108-116
61 Schortgen F, Bouadma L, Joly-Guillou ML, Ricard JD, Dreyfuss D, Saumon G. Infectious and inflammatory dissemination are affected by ventilation strategy in rats with unilateral pneumonia. Intensive Care Med 2004; 30 (04) 693-701
62 Schreiber T, Hueter L, Gaser E. et al. PEEP has beneficial effects on inflammation in the injured and no deleterious effects on the noninjured lung after unilateral lung acid instillation. Intensive Care Med 2006; 32 (05) 740-749
63 Hasan FM, Beller TA, Sobonya RE, Heller N, Brown GW. Effect of positive end-expiratory pressure and body position in unilateral lung injury. J Appl Physiol 1982; 52 (01) 147-154
64 Guérin C, Terzi N, Galerneau LM. et al. Lung and chest wall mechanics in patients with acute respiratory distress syndrome, expiratory flow limitation, and airway closure. J Appl Physiol (1985) 2020; 128 (06) 1594-1603
65 Chen L, Del Sorbo L, Grieco DL. et al. Airway closure in acute respiratory distress syndrome: an underestimated and misinterpreted phenomenon. Am J Respir Crit Care Med 2018; 197 (01) 132-136
66 Sun XM, Chen GQ, Zhou YM, Yang YL, Zhou JX. Airway closure could be confirmed by electrical impedance tomography. Am J Respir Crit Care Med 2018; 197 (01) 138-141
67 Scaramuzzo G, Spadaro S, Waldmann AD. et al. Heterogeneity of regional inflection points from pressure-volume curves assessed by electrical impedance tomography. Crit Care 2019; 23 (01) 119
68 Chen L, Del Sorbo L, Fan E, Brochard L. Reply to borges: the plausibility of “bronchiolotrauma”. Am J Respir Crit Care Med 2018; 197 (08) 1087-1088
69 Tsuchida S, Engelberts D, Peltekova V. et al. Atelectasis causes alveolar injury in nonatelectatic lung regions. Am J Respir Crit Care Med 2006; 174 (03) 279-289
70 Kunst PW, Böhm SH, Vazquez de Anda G. et al. Regional pressure volume curves by electrical impedance tomography in a model of acute lung injury. Crit Care Med 2000; 28 (01) 178-183
71 Bellani G, Laffey JG, Pham T. et al. LUNG SAFE Investigators, ESICM Trials Group. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA 2016; 315 (08) 788-800
72 Luhr OR, Antonsen K, Karlsson M. et al. The ARF Study Group. Incidence and mortality after acute respiratory failure and acute respiratory distress syndrome in Sweden, Denmark, and Iceland. Am J Respir Crit Care Med 1999; 159 (06) 1849-1861