Anatomical and functional intrapulmonary shunt in acute respiratory distress syndrome

Massimo Cressoni, Pietro Caironi, Federico Polli, Eleonora Carlesso, Davide Chiumello, Paolo Cadringher, Micheal Quintel, Vito Marco Ranieri, Guillermo Bugedo, Luciano Gattinoni

Research output: Contribution to journalArticle

Abstract

Objectives: The lung-protective strategy employs positive end-expiratory pressure to keep open otherwise collapsed lung regions (anatomical recruitment). Improvement in venous admixture with positive end-expiratory pressure indicates functional recruitment to better gas exchange, which is not necessarily related to anatomical recruitment, because of possible global/regional perfusion modifications. Therefore, we aimed to assess the value of venous admixture (functional shunt) in estimating the fraction of nonaerated lung tissue (anatomical shunt compartment) and to describe their relationship. Design: Retrospective analysis of a previously published study. Setting: Intensive care units of four university hospitals. Patients: Fifty-nine patients with acute lung injury/acute respiratory distress syndrome. Interventions: Positive end-expiratory pressure trial at 5 and 15 cm H2O positive end-expiratory pressures. Measurements and main results: Anatomical shunt compartment (whole-lung computed tomography scan) and functional shunt (blood gas analysis) were assessed at 5 and 15 cm H2O positive end-expiratory pressures. Apparent perfusion ratio (perfusion per gram of nonaerated tissue/perfusion per gram of total lung tissue) was defined as the ratio of functional shunt to anatomical shunt compartment. Functional shunt was poorly correlated to the anatomical shunt compartment (r2 = .174). The apparent perfusion ratio at 5 cm H2O positive end-expiratory pressure was widely distributed and averaged 1.25 ± 0.80. The apparent perfusion ratios at 5 and 15 cm H2O positive end-expiratory pressures were highly correlated, with a slope close to identity (y = 1.10•x -0.03, r2 = .759), suggesting unchanged blood flow distribution toward the nonaerated lung tissue, when increasing positive end-expiratory pressure. Conclusions: Functional shunt poorly estimates the anatomical shunt compartment, due to the large variability in apparent perfusion ratio. Changes in anatomical shunt compartment with increasing positive end-expiratory pressure, in each individual patient, may be estimated from changes in functional shunt, only if the anatomical-functional shunt relationship at 5 cm H2O positive end-expiratory pressure is known.

Original languageEnglish
Pages (from-to)669-675
Number of pages7
JournalCritical Care Medicine
Volume36
Issue number3
DOIs
Publication statusPublished - Mar 2008

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Positive-Pressure Respiration
Adult Respiratory Distress Syndrome
Perfusion
Lung
Blood Gas Analysis
Acute Lung Injury
Intensive Care Units
Gases
Tomography

Keywords

  • Adult
  • Computed tomography
  • Positive-pressure respiration
  • Pulmonary gas exchange
  • Regional blood flow
  • Respiratory distress syndrome

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

Cite this

Cressoni, M., Caironi, P., Polli, F., Carlesso, E., Chiumello, D., Cadringher, P., ... Gattinoni, L. (2008). Anatomical and functional intrapulmonary shunt in acute respiratory distress syndrome. Critical Care Medicine, 36(3), 669-675. https://doi.org/10.1097/01.CCM.0000300276.12074.E1

Anatomical and functional intrapulmonary shunt in acute respiratory distress syndrome. / Cressoni, Massimo; Caironi, Pietro; Polli, Federico; Carlesso, Eleonora; Chiumello, Davide; Cadringher, Paolo; Quintel, Micheal; Ranieri, Vito Marco; Bugedo, Guillermo; Gattinoni, Luciano.

In: Critical Care Medicine, Vol. 36, No. 3, 03.2008, p. 669-675.

Research output: Contribution to journalArticle

Cressoni, M, Caironi, P, Polli, F, Carlesso, E, Chiumello, D, Cadringher, P, Quintel, M, Ranieri, VM, Bugedo, G & Gattinoni, L 2008, 'Anatomical and functional intrapulmonary shunt in acute respiratory distress syndrome', Critical Care Medicine, vol. 36, no. 3, pp. 669-675. https://doi.org/10.1097/01.CCM.0000300276.12074.E1
Cressoni, Massimo ; Caironi, Pietro ; Polli, Federico ; Carlesso, Eleonora ; Chiumello, Davide ; Cadringher, Paolo ; Quintel, Micheal ; Ranieri, Vito Marco ; Bugedo, Guillermo ; Gattinoni, Luciano. / Anatomical and functional intrapulmonary shunt in acute respiratory distress syndrome. In: Critical Care Medicine. 2008 ; Vol. 36, No. 3. pp. 669-675.
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AU - Chiumello, Davide

AU - Cadringher, Paolo

AU - Quintel, Micheal

AU - Ranieri, Vito Marco

AU - Bugedo, Guillermo

AU - Gattinoni, Luciano

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N2 - Objectives: The lung-protective strategy employs positive end-expiratory pressure to keep open otherwise collapsed lung regions (anatomical recruitment). Improvement in venous admixture with positive end-expiratory pressure indicates functional recruitment to better gas exchange, which is not necessarily related to anatomical recruitment, because of possible global/regional perfusion modifications. Therefore, we aimed to assess the value of venous admixture (functional shunt) in estimating the fraction of nonaerated lung tissue (anatomical shunt compartment) and to describe their relationship. Design: Retrospective analysis of a previously published study. Setting: Intensive care units of four university hospitals. Patients: Fifty-nine patients with acute lung injury/acute respiratory distress syndrome. Interventions: Positive end-expiratory pressure trial at 5 and 15 cm H2O positive end-expiratory pressures. Measurements and main results: Anatomical shunt compartment (whole-lung computed tomography scan) and functional shunt (blood gas analysis) were assessed at 5 and 15 cm H2O positive end-expiratory pressures. Apparent perfusion ratio (perfusion per gram of nonaerated tissue/perfusion per gram of total lung tissue) was defined as the ratio of functional shunt to anatomical shunt compartment. Functional shunt was poorly correlated to the anatomical shunt compartment (r2 = .174). The apparent perfusion ratio at 5 cm H2O positive end-expiratory pressure was widely distributed and averaged 1.25 ± 0.80. The apparent perfusion ratios at 5 and 15 cm H2O positive end-expiratory pressures were highly correlated, with a slope close to identity (y = 1.10•x -0.03, r2 = .759), suggesting unchanged blood flow distribution toward the nonaerated lung tissue, when increasing positive end-expiratory pressure. Conclusions: Functional shunt poorly estimates the anatomical shunt compartment, due to the large variability in apparent perfusion ratio. Changes in anatomical shunt compartment with increasing positive end-expiratory pressure, in each individual patient, may be estimated from changes in functional shunt, only if the anatomical-functional shunt relationship at 5 cm H2O positive end-expiratory pressure is known.

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KW - Adult

KW - Computed tomography

KW - Positive-pressure respiration

KW - Pulmonary gas exchange

KW - Regional blood flow

KW - Respiratory distress syndrome

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