Efficacy and Safety of a Lung Recruitment Protocol in Children With Acute Lung Injury
Condition: Acute Respiratory Distress Syndrome; Acute Lung Injury
MeSH terms: Respiratory Distress Syndrome; Respiratory Distress Syndrome, Newborn; Acute Lung Injury; Lung Injury; Wounds and Injuries
Study type: Interventional

Summary: 
      Lung units which participate in gas exchange are known as 'recruited' lung. Patients with
      lung injury suffer from a proportion of units which do not participate in gas exchange (i.e.
      the derecruited state), which results in impaired gas exchange and induces an inflammatory
      cascade. Currently, there is no clinical practice guideline in our intensive care unit
      regarding lung recruitment strategies for children with lung injury. While many studies have
      demonstrated efficacy (ability to open the lung) and safety of recruitment maneuvers in
      adults, no such studies have been performed in children.

      The primary purpose of this study is therefore to demonstrate the safety and efficacy of a
      recruitment protocol designed to maximally recruit collapsed lung in children with acute lung
      injury. Each study patient will follow a recruitment protocol (see Appendix 2). Two
      'controls' will be utilized in this study: baseline ventilation (no recruitment maneuver) and
      the open lung approach (a sustained inflation followed by increased PEEP). Efficacy will be
      defined as an improvement in lung volume (as measured by nitrogen washout and electrical
      impedance tomography), and by an improvement in measured arterial partial pressure of oxygen.
      Safety will be defined as the incidence of barotrauma and hemodynamic consequences which
      occur during the protocol.

      A secondary purpose of this study will be to further validate electrical impedance tomography
      (EIT) as a non-invasive tool describing the lung parenchyma by comparing it to an accepted
      standard method of measuring lung volumes, the multiple breath nitrogen washout technique.
      Validation of EIT would allow clinicians to have a non-invasive image of a patient's lungs
      without the risks imposed by radiography.

      The information we learn will be instrumental in defining an optimal strategy for lung
      recruitment in children with lung injury.
    

Detailed description: 
      I. Introduction A. Background Lung units which participate in gas exchange are known as
      'recruited' lung. Patients with lung injury suffer from a proportion of units which do not
      participate in gas exchange (i.e. the derecruited state), at times resulting in impaired gas
      exchange. Derecruitment of alveoli may also cause intrapulmonary shunting and worsen lung
      injury through atelectotrauma7. Outcomes in acute respiratory distress syndrome have improved
      significantly Is this really true? since clinicians have begun to employ lung protective
      strategies, including low-tidal volume ventilation and permissive hypercapnea8, 9. However,
      low-tidal volume ventilation has been recognized to decrease recruited lung volume, a
      phenomenon which persists despite the aggressive positive end-expiratory pressure (PEEP)
      strategy employed in ARDSNet studies4. Atelectasis associated with low-tidal volume
      ventilation is relieved through the use of so-called sign breaths, or recruitment breaths10.
      Further, the proportion of lung remaining in the derecruited state may contribute to the
      morbidity and mortality associated with acute respiratory distress syndrome (ARDS)11. In
      adults, several strategies have been utilized to recruit the lung: sustained inflation (SI)
      and the maximal recruitment strategy. The so-called open lung approach (OLA) includes an SI
      followed by the setting of PEEP to the measured lower inflection point of the PV curve. An
      alternative approach to setting PEEP is a decremental PEEP titration, which includes the
      sequential lowering of PEEP until a predetermined decrement in PaO2 or SaO2 occurs. Studies
      which have not included a strategy for maintaining lung recruitment following a recruitment
      maneuver have all been studied.

      The impact of lung recruitment in the long-term course of ARDS is not yet clear. It is clear
      that lung recruitment is most effective earlier in the course of ALI/ARDS. Grasso et al
      demonstrated that patients who received a recruitment maneuver on day 1±0.3 of ARDS could be
      recruited, versus patients recruited on day 7±1. Similarly, Gattinoni et al11 and Crotti et
      al5 found limited recruitment in patients who were well along in the course of ARDS. Borges
      et al,6 Tugrul et al,12 and Girgis et al all recruited patients early in the course of ARDS,
      and each found marked lung recruitment, on average, in all the patients studied. Each of
      these studied demonstrated an ability to improve oxygen saturations and (sometimes studied)
      end-expiratory lung volume. While no study has examined the effect of this change on
      morbidity or mortality, in children hypoxemia is known to be a common cause of morbidity.
      Importantly in children, treatment of hypoxia often drives escalating ventilator settings,
      the use of high frequency oscillatory ventilation (HFOV) or the use of extra-corporeal
      membrane oxygenation (ECMO). Early recruitment in children with ALI/ARDS may prevent the need
      for escalation of care towards these more invasive, and risk-imposing therapies.

      Currently, there are no clinical practice guidelines or standard of care regarding lung
      recruitment strategies for children with lung injury. To date, no studies have been performed
      in children documenting the efficacy or safety of any of the strategies utilized in intensive
      care. The primary aim of this study is to demonstrate the efficacy and safety of sustained
      inflation and maximal recruitment maneuvers in children with lung injury.

      B. Lung Recruitment Maneuvers

        1. Sustained Inflations (SI) Sustained inflations (SI) are commonly utilized in the
           intensive care unit as a recruitment maneuver. In SI, the patient is given a prolonged
           positive pressure breath (usually between 30 and 45 cm H2O) lasting between 15 and 40
           seconds. Clinically, this maneuver is applied following a derecruitment, such as
           suctioning, or when the patient exhibits hypoxemia. This strategy is currently employed
           in the Children's Hospital Boston Medical-Surgical Intensive Care Unit in some patients
           with lung injury, though there is no published evidence of its safety or efficacy in
           children. Could we put the 3 SI studies in premature infants that use 20-40 cmH20
           followed by CPAP? 1 was a rabbit study. The studies described below regard sustained
           inflation recruitment maneuvers.

             1. Tugrul, et al12 studied the effect of SI in 24 adults with ARDS. SI included 45 cm
                H2O for 30 seconds, followed by a decremental PEEP titration from 20 cm H2O down,
                titrating to saturations. P/F ratio increased >200 in 11/24 patients, which
                persisted at 6 hours post-maneuver in 9/24 patients. Barotrauma was not observed in
                any patients.

             2. Richard, et al studied4 the effect of SI (45 cm H2O for 15 seconds) in 10 adults
                with ARDS ventilated with a low-tidal volume strategy. The maneuver induced a
                significant increase in recruited lung volumes (175±108 ml pre-maneuver versus
                254±137 ml post-maneuver). This improvement was associated with an increase in
                arterial oxygen saturations. There was no report of sustainability of recruitment,
                nor of adverse effects.

             3. Lapinski, et al13 studied the safety and efficacy of the SI maneuver in 14 adults
                with ARDS. The pressure utilized in the maneuver was the lesser of 45 cm H2O or the
                plateau pressure utilized in 12 mL/kg tidal volume breaths; the maneuver was held
                for 20 seconds. Oxygen saturations increased from 86.9 ± 5.5 to 94.3 ± 2.3% by 10
                minutes, which was maintained at 4 hours in 10/14 patients. The four in whom
                saturations fell had PEEP levels below 10 cm H2O. The systolic blood pressure
                decreased during the 20 second inflation in some patients, mean change of 6.9 mm
                Hg, which reversed rapidly following release of the maneuver in all patients. No
                barotrauma was noted in any patient at 24 hour followup.

             4. Pelosi, et al10 studied the effect of three consecutive 'sigh' breaths (one with
                plateau pressure of 45 cm H2O but of normal duration) in 10 adults with ARDS. After
                1 hour of 3 sigh breaths per minute, end-expiratory lung volume (measured by He
                dilution) increased from 1.49±0.58 to 1.91±0.67 L, and an increase in PaO2 from
                92.8±18.6 to 137.6±23.9 mm Hg, compared with the same ventilator settings without
                sigh breaths. Lung elastance and ventilation also increased. No adverse effects
                were noted.

             5. Toth, et al studied the cardiac and respiratory changes which occur in SI (40 cm
                H2O for 40 seconds) in 18 adults with ARDS. The PaO2 increased from pre-recruiting
                maneuver to following the 60 minute followup period (203±108 vs. 322±101 mm Hg, p <
                .001). Cardiac index (CI) and the intrathoracic blood volume (ITBV) decreased
                following the recruiting maneuver (CI, 3.90±1.04 vs. 3.62±0.91 L/min/m2, p < .05;
                ITBVI, 832±205 vs. 795±188 mL/m2, p < .05). There was no correlation with CI and
                mean arterial pressure, and no significant changes occurred in mean arterial blood
                pressure.

             6. In perhaps the largest study of sustained inflations in the protective ventilation
                era, Meade, et al14 studied 983 adults with ARDS utilizing lung protective
                strategies (tidal volumes 6 mL/kg) in both groups. The experimental group utilized
                SI recruitment maneuvers (40 cm H2O for 40 seconds), higher levels of PEEP
                (14.6±3.4 in the so-called 'lung open ventilation' group versus 9.8±2.7 in the
                control group), and higher plateau pressures (30.2±6.3 versus 24.9±5.1 cm H2O) than
                the control group, which did not utilize recruitment maneuvers. While there was no
                difference in all-cause mortality, the experimental group had lower rates of
                refractory hypoxemia (4.6% vs 10.2%; RR, 0.54), death with refractory hypoxemia
                (4.2% vs 8.9%; RR, 0.56), and less frequent use of escalated therapies (defined as
                high frequency ventilation, inhaled nitric oxide, jet ventilation, or
                extra-corporeal support) (5.1% vs 9.3%; RR, 0.6). This lends credence to the notion
                that effective recruitment of children early in acute lung injury may avert
                escalation of therapy and decrease the mortality due to severe hypoxia.

        2. Pressure control ventilation (PCV) recruitment maneuver In contrast to a SI, ventilating
           patients with increased plateau pressures and increased PEEP levels has also been used
           as a recruiting maneuver. In this case, the patient is temporarily placed on higher
           ventilator pressures than would be used to ventilate a patient otherwise. A combination
           of PEEP and plateau pressures helps to recruit atelectatic alveoli. Pressure control
           ventilation is the mode of choice in such patients because in it the plateau pressure is
           set, and therefore kept constant (in contrast to volume controlled ventilation). Thus, a
           known plateau pressure (which participates in lung recruitment) is delivered. Following
           are the salient studies utilizing a PCV recruitment maneuver. ? Athanasios "TLC
           maneuver" in anesthetized children? Small study treating intraoperative atelectisis.

             1. Borges, Amato, et al6 have performed the most convincing and complete study of the
                maximal recruitment maneuver to date. In it, they studied 26 adults early in the
                course of ARDS comparing the open lung approach (including SI of 40 cm H2O for 40
                seconds, followed by PEEP set at Pflex + 2 cm H2O, described below) with the
                maximal recruitment strategy, performed in sequence. Maximal recruitment was
                defined as a PaO2 plus PaCO2 exceeding 400 mm Hg, indicative of minimal
                intrapulmonary shunting. The strategy included pressure controlled ventilation of
                15 cm H2O, with PEEP increased in 5 cm H2O increments every 5 minutes (maximum PEEP
                45 cm H2O) until maximal recruitment was achieved. Maximal recruitment was achieved
                in 24/26 patients, two thirds of which were achieved by a PEEP of 30 cm H2O.
                Utilizing a PEEP titration to maintain lung recruitment (see below), PaO2 remained
                above 400 (lungs fully recruited) in all patients at 6 hours. The procedure was
                tolerated hemodynamically in all patients and the long-term incidence of barotrauma
                in study patients (7.7%) was lower than the recognized incidence in ARDSNet studies
                (10-11%)8.

             2. Crotti, et al5 studied five adults with ALI/ARDS with varying plauteau pressures
                (10, 15, 20, 30, 35, 40, 45 cm H2O) and PEEP levels (5, 10, 15, 20 cm H2O).
                End-inspiratory and end-expiratory thoracic CT imaging was obtained with each
                combination of plateau pressure and PEEP. Percentage of lung recruited (as
                determined radiographically) increased in a nearly linear fashion with increasing
                plateau pressures (Figure 1). The maximal opening frequency occurred at 20 cm H2O,
                suggesting that plateau pressures exceeding 20 cm H2O would be most beneficial in
                lung recruitment. No measures of gas exchange or adverse events were studied.

             3. Foti, et al15 compared changes in oxygenation and end-expiratory lung volumes at
                increasing PEEP levels with superimposed volume controlled ventilation versus a
                sustained inflation maneuver in 15 adults with ARDS. Although recruitment was
                variable (due to the use of VCV, hence variable plateau pressures), he found that
                maximal increase in oxygenation occurred at high sustained levels of PEEP (mean 16
                cm H2O for 30 minutes) when compared with 30 second recruitment maneuvers and low
                PEEP (mean of 9 cm H2O). The PEEP/plateau protocol was not associated with any
                hemodynamic alterations, as with the sustained inflation maneuver.

             4. Villagra, et al, studied a recruiting maneuver utilizing 2 minutes of ventilation
                using pressure-controlled ventilation (PCV) in 18 adults with early ARDS. For the
                RM, PEEP was set 3 cm H2O above the upper inflection point of the PV curve, and
                peak pressures set to 50. Importantly, RM peak pressures did not differ
                significantly from baseline ventilation (43.6±7.6 pre-RM, 47±4.5 during RM, and
                42.8±7.1 cm H2O post-RM), although PEEP did (14±1.3 pre-RM vs 30±4.9 cm H2O). The
                investigators did not find a significant difference in PaO2 following the
                recruiting maneuver (127±63 pre-RM, 162±108 during, and 149±85 cm H2O post-RM).
                This finding implies several important findings regarding lung recruitment. First,
                the peak pressure represents a significant determinant in lung recruitment. By
                contrast, Borges, et al were able to fully recruit all 18 ARDS patients by using
                driving pressures differed significantly from pre-RM in the maximal recruitment
                phase (50-60 cm H2O during recruitment vs 30 cm H2O at baseline). Further, the
                recruiting maneuver utilized here was only 2 minutes, versus the incremental
                titration utilized by Borges which lasted 4 minutes in each phase. While not
                systematically studied, the lack of significant improvement in PaO2 post-RM found
                in this study suggests that recruitment utilizing PCV may be a function of time and
                peak pressures utilized in the RM.

             5. Medoff,3 et al presented a single patient with refractory hypoxemia. Management
                included repeated sustained inflations with PEEP set just above Pflex based on the
                PV curve. A recruiting maneuver including 20 cm H2O of PEEP and 40 cm H2O
                distending pressure for 2 minutes was performed. The patient exhibited marked
                improvement in oxygenation and near-complete recruitment of the lung by CT scan
                (see Figure 2).

             6. While all of the aforementioned studies achieved successful recruitment, Gattinoni,
                et al11 studied 68 adults with late ARDS (5±6 days ventilation at enrollment) who
                failed to successfully recruit. Recruitment maneuvers included pressure-controlled
                ventilation with peak pressure of 45 cm H2O, PEEP of 5 cm H2O, and respiratory rate
                of 10. PEEP levels were subsequently applied in random order, between 5 and 15 cm
                H2O. He found that study patients had only 13±11% recruitable lung by CT scan.
                Amongst all patients, he found that 24% of lung tissue was non-recruitable, even at
                airway pressures of 45 cm H2O. No markers of gas exchange were measured.

      It is important to note three aspects of this study which are likely responsible for the
      excessively high percentage of non-recruitable lung, in contrast with the highly successful
      recruitment strategy outlined by Borges, et al. First, Borges studied patients early in the
      ARDS course (median, 2 days) while Gattinoni studied late ARDS. Second, Borges utilized peak
      pressures as high as 60 cm H2O, while Gattinoni utilized pressures up to 45 cm H2O. Finally,
      Gattinoni did not practice a PEEP titration, but lowered PEEP to 5 cm H2O following
      recruitment maneuvers. Thus, Gattinoni's study highlights the importance of high peak
      pressures in lung recruitment, of recruiting early in ARDS, and of a decremental PEEP
      titration to maintain lung recruitment.

      C. Strategies of Maintaining Recruitment The application of positive end-expiratory pressure
      is known to prevent repetitive derecruitment-recruitment stresses on lung tissue. In an
      animal model of acute lung injury, Farias showed histologic and biochemical evidence of
      atelectotrauma is averted when PEEP is applied following lung recruitment7. The two principal
      strategies to prevent derecruitment following a recruitment maneuver include the open lung
      approach and decremental PEEP titration.

        1. Open Lung Approach In the open lung approach, PEEP is set just above the lower
           inflection point (also known as Pflex) of the patient's pressure-volume curve. This
           theoretically prevents the PEEP from decreasing below the zone of underdistension.

             1. In a second part of the study mentioned above, Richard, et al4 also studied the
                effect of increasing PEEP relative to the measured LIP (LIP + 4 cm H2O, no SI)
                compared to PEEP set at the lower inflection point following SI. In 10 adults
                ventilated with low-tidal volume ventilation, measured lung volumes were 175±108 at
                PEEPLIP versus 332±91 ml at PEEPLIP+4. This increase was even more notable in
                patients ventilated with high tidal volumes (10 mL/kg), demonstrating the role of
                plateau pressures (in addition to PEEP) in alveolar recruitment (see Figure 3).

             2. Amato, et al16 studied the effects of a 'protective ventilation strategy' in 53
                patients with ARDS. The protective ventilation group received recruitment maneuvers
                via sustained inflation (35-40 cm H2O for 40 seconds) followed by PEEP set at LIP +
                2 cm H2O. The control group received a PEEP titrated to saturations, no recruiting
                maneuvers. The protective ventilation group had a dramatic decrease in 28 day
                all-cause mortality (38% vs 71%, p<0.001). However, the control group also received
                high tidal volume ventilation (12 mL/kg), later proven to be a significant
                determinant in ARDS mortality.8 Therefore, the contribution of RM and open lung
                approach to the improved mortality of this study, if any, is difficult to conclude.

        2. Decremental PEEP Titration In a decremental PEEP titration, following a recruiting
           maneuver, the PEEP is set at a high level, often between 20 and 26 cm H2O. PEEP is
           decreased incrementally, and markers of lung inflation (e.g. gas exchange or measured
           lung volume) are followed. When evidence of atelectasis occurs, PEEP is held at or just
           above this level, often termed 'optimal PEEP.'

             1. Borges, Amato, et al6 describe a PEEP titration following a maximal recruitment
                protocol and compare it to the open lung approach (PEEP set at Pflex + 2 cm H2O).
                Following a maximal recruitment strategy (described above), PEEP was set at 25 cm
                H2O and decreased by 2 cm H2O every 4 minutes until PaO2 + PaCO2 < 380 mm Hg, then
                increased by 2 cm H2O (optimal PEEP, mean 20±5 cm H2O). Using this strategy, PaO2
                was sustained at levels above 400 mm Hg at 30 minute followup in all 24 patients
                (see Figure 4, top), and above 450 in the 16 patients followed for 6 hours. This
                correlated with a percent mass of collapsed tissue as measured by CT scan of <5% at
                end of PEEP titration and at 30 minute followup (see Figure 4, bottom).

             2. Toth, et al17 described a decremental PEEP titration following a SI recruiting
                maneuver. Following SI at 40 cm H2O for 40 seconds, PEEP was set at 26 cm H2O, then
                decreased by 2 cm H2O every 4 minutes until the PaO2 decreased by >10% of its peak
                value. The PEEP 2 cm H2O above this was defined as optimal PEEP. Optimal PEEP was
                found to actually be lower than the patients' baseline PEEP (prior to protocol
                initiation, 17±3 vs 15±4 cm H2O). The PaO2 following the recruiting maneuver
                (203±108 at baseline PEEP vs 328±132 cm H2O) sustained at the 30 minute followup
                period (266±121 cm H2O, p<0.05 compared to baseline).

      D. Estimating Lung Volumes Currently, the ability to determine whether a patient is at, below
      or above their ideal functional residual capacity is deduced from surrogate measurements,
      including lung appearance of the chest radiograph, vital sign trends (particularly
      oxygenation), and pressure-volume (P-V) curves generated by modern ventilators. In this
      study, we will utilize an established method of determining lung volume (MBNW) to study lung
      volumes.

        1. Pressure-Volume Curves The pressure-volume curve represents the continual relationship
           between changes in pressure and changes in volume of the lung. The slope of the line
           represents the compliance of the lung. In Figure 5, note the three lines which comprise
           the inspiratory limb (lower curve). The leftmost line represents noncompliant,
           atelectatic lung. The point at which the slope changes is known as the lower infection
           point, also known as Pflex. In the open lung approach (discussed later), PEEP is set to
           a pressure just above the lower inflection point. Physiologically, it is hypothesized
           that this is the point at which all atelectatic segments of lung are recruited, and that
           disallowing ventilator pressures from dropping below this at any point (by setting PEEP
           above this level) minimizes atelectasis. The point which distinguishes the second change
           in slope of the line (becoming flat again) is known as the upper inflection point (UIP).
           Pressures above this point represent overdistended, noncompliant alveoli, and thus this
           point represents the pressure at which the compliance of the lung decreases
           dramatically. In this protocol, the PV curve will be measured for each patient and the
           UIP utilized as the ceiling pressure at any point in the protocol. In this way, we will
           recruit compliant areas of the lung without the risks of overdistension.

        2. Nitrogen Multiple Breath Washout Technique (MBNW)

           MBNW has been utilized in a number of clinical studies, and is considered to be a gold
           standard in the measurement of lung volume18-21. Currently, the most accurate way to
           measure the volume of the lung is through dilution of a known amount of a gas with low
           solubility be rebreathing in a closed system. The changes in concentration with
           sequential breaths allow a calculation of the volume of distribution of the gas. One gas
           which has been utilized for this purpose is nitrogen22, appealing due to its ubiquitous
           presence in the environment. Measurement of nitrogen gas concentrations, however, is
           available only using gas chromatography or mass spectrometry, neither of which is
           clinically practical. Recently, a technique has been validated by which the partial
           pressure of nitrogen is calculated as the residual of partial pressures of oxygen gas,
           carbon dioxide gas and nitrogen gas, which together comprise the only three important
           gases in a ventilator circuit. The former two gases are readily measured in a ventilator
           circuit in real time, but of course vary widely with the metabolic state of the patient.
           Stenqvist has developed the NMBW technique to calculate FRC using the changes in exhaled
           O2 and CO2, manipulating inspired oxygen concentration to alter fraction of inspired
           nitrogen23. FRC is calculated as follows:

           FiN2 = 1-FiO2 (set by ventilator) FeO2 = 1-FeO2 (measured)-FeCO2 (measured)

           Inspired and expired alveolar tidal volumes are calculated using O2 consumption (VO2)
           and CO2 production (VCO2) as calculated by indirect calorimetry24:

           Volumes of inspired and expired nitrogen gas associated with a single breath are
           calculated from end-tidal nitrogen content (EtN2, inferred from measured expired CO2 and
           oxygen content), inspired nitrogen fraction (FiN2) and inspiratory and expiratory
           alveolar tidal volume as follows:

           Before making the incremental 10% change in FiN2 via manipulating FiO2, baseline values
           for VO2, VCO2 and ETN2 are made. VO2 and VCO2 are assumed to be constant throughout the
           measurement. The FiN2 is then manipulated, and FRC estimated as follows:

           Measurement of FRC using this methodology in a lung model of known oxygen consumption
           and lung volumes23 revealed excellent precision (mean FRC 103 5%) even when utilizing
           incremental changes in FiO2 from 0.9 to 1.0. Precision in adult patients with
           respiratory insufficiency revealed excellent precision amongst measurements.

        3. Electrical Impedance Tomography (EIT) Electrical impedance tomography capitalizes on
           changes in impendence in air-filled versus tissue-filled spaces to characterize and
           quantify regional distribution of lung volume at the bedside. Significant work has been
           done in the past decade to validate the technology in animals25 and in humans26, 27. The
           technology utilizes a series of 16 electrodes placed across the patient's chest (Figure
           6). As small currents are passed between the electrodes, impedance is measured between
           and amongst the series. Through a complex interrogation and manipulation of these
           impedance values, a two-dimensional image is formed (Figure 7), and has been shown to
           correlate with clinical and radiographic changes in patients27. In ten mechanically
           ventilated adults with ARDS, end-expiratory lung volume as determined by nitrogen
           washout correlated well with end-expiratory lung impedance with an r2 of 0.95.26 The
           ability to estimate lung volume non-invasively and in real time may significantly
           improve outcomes in patients with lung injury. Specifically, the ability to determine a
           patient's ideal functional residual capacity and ventilate them towards that goal may
           improve oxygen delivery by maximizing pulmonary compliance and minimizing pulmonary
           vascular resistance. This study seeks to utilize varying levels of PEEP to alter
           end-expiratory volume, using EIT and other surrogate measures to confirm efficacy,
           measuring oxygenation and shunt fraction as the clinical end points. Should this study
           demonstrate the ability to effectively recruit lung and minimize shunt fractions using
           an aggressive PEEP strategy, further studies of clinical benefit from this will be
           warranted.

        4. Exhaled Breath Condensate (as measure of lung health) There is a growing body of
           evidence regarding changes in airway lining fluid (ALF) pH in acute and chronic
           respiratory diseases that are characterized, at least in part, by inflammation. It has
           been demonstrated that the pH of ALF is low (acidic) in multiple pulmonary inflammatory
           diseases including asthma28, cystic fibrosis29, pneumonia, and ARDS30-32, and that this
           pH can be detected continuously, safely and non-invasively in exhaled breath condensate
           (EBC)33. The pH of EBC may be a safe, non-invasive screening tool for progression of
           ARDS, and of lung recruitment. It has anecdotally been shown to predict respiratory
           failure and impending respiratory infection (unpublished data). As seen in Figure 4
           (left), the EBC pH is a marker exhibiting rapid turnover and thus may be valuable for
           real-time monitoring of lung pathology.

      Continuous exhaled breath condensate pH collection and assay system (ALFA monitor,
      Respiratory Research, Inc., Austin, Texas) consists of a condenser attached to the expiratory
      limb of the ventilator. Exhaled breath condensate is collected continuously from the
      expiratory port, condensed in a cooling chamber, CO2 removed, and collected in an inferior
      chamber where pH is continuously read. This yields a continuous, responsive measure from
      ventilated patients, which (1) takes samples from an exhaust port on the outside of the
      ventilator circuit, and (2) adds no measurable resistance to the ventilator circuit. The
      measurement of EBC in patients with lung injury may serve as an early marker of
      derecruitment.

      II. Study Objectives Specific Aim 1: To demonstrate the efficacy of the a maximal recruitment
      strategy to increase lung volumes and improve oxygenation in children with acute lung injury,
      utilizing multiple breath nitrogen washout (MBNW) and electrical impedance tomography (EIT)
      as measures of lung volume. (Hypothesis: Lung volumes and oxygenation will increase following
      the maximal recruitment protocol as compared to those during 'baseline ventilation' or the
      'open lung approach.') Specific Aim 2: To compare lung volumes as measured by MBNW and EIT at
      varying end-expiratory lung volumes. (Hypothesis: Lung volumes as measured by MBNW will
      correlate with those obtained by EIT.)
    

Intervention name(s): Recruitment maneuver
Intervention type(s): Procedure
Intervention description(s): Three types of maneuvers will be performed.
6cc/kg tidal volumes at an appropiate rate on current prescribed PEEP level.
6cc/Kg tidal volumes at an appropiate rate following a 40 cmH2O for 40 seconds maneuver returning to a pflex plus 2 cmH2O PEEP level.
PEEP titration starting a 15 cmH2O and increasing in 5 cmH2O increases until the PaO2+PaCO2 is 400 or higher.
Other intervention name(s): PV maneuver + 2 cmH2O; 40 cmH2O for 40 seconds; PEEP titration until P400
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Pediatric Acute Respiratory Distress Syndrome (ARDS); Pediatric Acute Lung Injury (ALI)