Recruitment maneuver: Does it promote bacterial translocation?

OBJECTIVEHigh peak airway opening pressures (Pao) are used routinely during recruitment maneuvers to open collapsed lung units. High peak Pao, however, can cause lung injury as evidenced by translocation of intratracheally inoculated bacteria. In this study we explored whether recruitment maneuvers that used high Pao could cause translocation of the intratracheally inoculated Pseudomonas aeruginosa from the alveoli into the systemic circulation. DESIGNProspective, randomized, animal study. SETTINGExperimental animal care laboratory. SUBJECTSEighteen male Sprague Dawley rats. INTERVENTIONSRats were anesthetized, tracheostomized, and ventilated with 14 cm H2O peak Pao and 0 cm H2O positive end-expiratory pressure (PEEP) in pressure-controlled ventilation (frequency, 30 bpm; inspiratory/expiratory ratio, 1:2; Fio2, 1). Intratracheal inoculation of 500 μL of saline containing 1 × 10 colony forming units/mL P. aeruginosa was performed before randomization into three groups (n = 6 in each)a low-pressure group (14 cm H2O peak Pao, 0 cm H2O PEEP), a high-pressure group (45 cm H2O peak Pao, 0 cm H2O PEEP), and a recruitment maneuver group (14 cm H2O peak Pao, 0 cm H2O PEEP, and a recruitment maneuver sustained inflation of 45 cm H2O continuous positive airway pressure for 30 secs every 15 mins). Blood samples for blood gas analysis were obtained before intratracheal instillation of bacteria and at the end of the experimental protocol (2 hrs). Blood cultures were obtained before and after bacterial instillation at 30-min intervals during the experiment. Blood samples were cultured directly in sheep blood, MacConkey, and Iso-Sensitest agars and were observed on the second day. Bacteremia was defined as the presence of one or more colonies of P. aeruginosa in 1 mL of blood. MEASUREMENTS AND MAIN RESULTSThe blood cultures were positive for P. aeruginosa in only six rats in the high-pressure group and remained negative throughout the study period in the low-pressure and recruitment maneuver groups. Oxygenation deteriorated in all groups after intratracheal instillation of bacteria. In the high-pressure group, oxygenation decreased from 417 ± 67 mm Hg to 79 ± 20 mm Hg (p = .004), whereas in the low-pressure and recruitment maneuver groups Pao2 decreased from 410 ± 98 mm Hg and 383 ± 78 mm Hg to 287 ± 105 mm Hg (p = .031) and 249 ± 59 mm Hg (p = .11), respectively. CONCLUSIONIntermittent recruitment maneuvers applied as a sustained inflation superimposed on low-pressure v