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Original Article
Tidal changes on CT and progression of ARDS


Background Uncertain prediction of outcome in acute respiratory distress syndrome (ARDS) impedes individual patient management and clinical trial design.

Objectives To develop a radiological metric of injurious inflation derived from matched inspiratory and expiratory CT scans, calibrate it in a model of experimental lung injury, and test it in patients with ARDS.

Methods 73 anaesthetised rats (acid aspiration model) were ventilated (protective or non-protective) for up to 4 hours to generate a spectrum of lung injury. CT was performed (inspiratory and expiratory) at baseline each hour, paired inspiratory and expiratory images were superimposed and voxels tracked in sequential scans. In nine patients with ARDS, paired inspiratory and expiratory CT scans from the first intensive care unit week were analysed.

Results In experimental studies, regions of lung with unstable inflation (ie, partial or reversible airspace filling reflecting local strain) were the areas in which subsequent progression of injury was greatest in terms of progressive infiltrates (R=0.77) and impaired compliance (R=0.67, p<0.01). In patients with ARDS, a threshold fraction of tissue with unstable inflation was apparent: >28% in all patients who died and ≤28% in all who survived, whereas segregation of survivors versus non-survivors was not possible based on oxygenation or lung mechanics.

Conclusions A single set of superimposed inspiratory–expiratory CT scans may predict progression of lung injury and outcome in ARDS; if these preliminary results are validated, this could facilitate clinical trial recruitment and individualised care.

  • ventilator-induced lung injury\
  • acute lung injury
  • artificial respiration
  • computed tomography
  • diagnostic imaging

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  • Contributors MC and YX share lead authorship role in this work. MC, YX, HH, SK, JCG, BPK and RRR: study conception and design; MC, YX, GB, LG and NM: acquisition of data; MC, YX, HH, SK, JR, NT, JG, BPK and RRR: analysis and interpretation of data; MC, YX, HH, SK, JR, JC and BPK: drafting of manuscript; MC, YX, GB, HH, SK, JC, BPK and RRR: critical revision.

  • Funding This work was supported by NIH (Bethesda, Maryland, USA) grants R01$HL116342 and R01$HL124986. Maurizio Cereda was supported by a grant from the Foundation for Anesthesia Education and Research (Schaumburg, Illinois, USA) and from the Society of Critical Care Anesthesiologists (Park Ridge, Illinois, USA), and by the Transdisciplinary Awards Program in Translational Medicine and Therapeutics (Philadelphia, Pennsylvania, USA). Brian P. Kavanagh is supported by operating funds from the CIHR (Ottawa, Ontario, Canada) and holds the Dr. Geoffrey Barker Chair in Critical Care Medicine.

  • Competing interests None declared.

  • Ethics approval Ethical committee of University of Milan-Bicocca.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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