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Correspondence |

Recruitment Maneuvers in ARDS … More Questions Than Answers FREE TO VIEW

Ajmal Khan, MD; Ritesh Agarwal, MD, DM, FCCP
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From the Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research.

Correspondence to: Ritesh Agarwal, MD, DM, FCCP, Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh-160012 India; e-mail: riteshpgi@gmail.com


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(3):737. doi:10.1378/chest.07-2950
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In an interesting article in CHEST (November 2007), Talmor and colleagues1 demonstrate that recruitment maneuvers are well tolerated in ARDS, with no major hemodynamic or immunologic evidence of deterioration within the first hour of a recruitment maneuver. However, certain aspects of this study are not clear from the article.

In this study, eight out of the 26 patients had intraabdominal pathologic results wherein the pressures applied during the study may not be appropriate, because higher airway pressures are required to generate an equivalent transpulmonary pressure in the patient with increased intraabdominal pressure.2 The use of bladder pressure measurements may help in determining the intraabdominal pressure and may help in this regard. Furthermore, stratifying the results into abdominal and extraabdominal categories may alter the results.

Gattinoni et al3 showed that patients with extrapulmonary ARDS (ARDSexp) have a greater response rate to recruitment maneuvers than those with pulmonary ARDS (ARDSp). Thus, patients with pneumonia may have a limited amount of recruitable lung tissue, and the higher pressure may overinflate normal lung rather than aerating the consolidated tissue. So, further separating the results into ARDSp and ARDSexp may lead to greater insight in the study. A series by Gattinoni et al4 found that patients with ARDSp had a higher percentage of recruitable lung than patients with ARDSexp when using CT scanning of the whole lung to quantify recruitment. Thus, CT scanning should ideally be performed when evaluating the effects of recruitment maneuvers. Finally, two (7.69%) out of 26 patients in this study did show a hemodynamic compromise and early termination of the recruitment maneuver, which definitely puts a question mark on the safety of this maneuver in critically ill patients with ARDS.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Talmor D, Sarge T, Legedza A, et al. Cytokine release following recruitment maneuvers. Chest. 2007;1325:1434-1439. [CrossRef] [PubMed]
 
Lapinsky SE, Mehta S. Bench-to-bedside review: recruitment and recruiting maneuvers. Crit Care. 2005;91:60-65. [CrossRef] [PubMed]
 
Gattinoni L, Pelosi P, Suter PM, Pedoto A, Vercesi P, Lissoni A. Acute respiratory distress syndrome caused by pulmonary and extrapulmonary disease. Different syndromes? Am J Respir Crit Care Med. 1998;1581:3-11. [PubMed]
 
Gattinoni L, Caironi P, Cressoni M, et al. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med. 2006;35417:1775-1786. [CrossRef] [PubMed]
 

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References

Talmor D, Sarge T, Legedza A, et al. Cytokine release following recruitment maneuvers. Chest. 2007;1325:1434-1439. [CrossRef] [PubMed]
 
Lapinsky SE, Mehta S. Bench-to-bedside review: recruitment and recruiting maneuvers. Crit Care. 2005;91:60-65. [CrossRef] [PubMed]
 
Gattinoni L, Pelosi P, Suter PM, Pedoto A, Vercesi P, Lissoni A. Acute respiratory distress syndrome caused by pulmonary and extrapulmonary disease. Different syndromes? Am J Respir Crit Care Med. 1998;1581:3-11. [PubMed]
 
Gattinoni L, Caironi P, Cressoni M, et al. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med. 2006;35417:1775-1786. [CrossRef] [PubMed]
 
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