{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,31]],"date-time":"2026-10-31T09:18:46Z","timestamp":1793438326623,"version":"4.5.0"},"reference-count":41,"publisher":"Oxford University Press (OUP)","issue":"10","license":[{"start":{"date-parts":[[2018,5,1]],"date-time":"2018-05-01T00:00:00Z","timestamp":1525132800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2018,5,15]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Rationale<\/jats:title>\n                    <jats:p>In acute respiratory distress syndrome (ARDS), atelectatic solid-like lung tissue impairs transmission of negative swings in pleural pressure (Ppl) that result from diaphragmatic contraction. The localization of more negative Ppl proportionally increases dependent lung stretch by drawing gas either from other lung regions (e.g., nondependent lung [pendelluft]) or from the ventilator. Lowering the level of spontaneous effort and\/or converting solid-like to fluid-like lung might render spontaneous effort noninjurious.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To determine whether spontaneous effort increases dependent lung injury, and whether such injury would be reduced by recruiting atelectatic solid-like lung with positive end-expiratory pressure (PEEP).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Established models of severe ARDS (rabbit, pig) were used. Regional histology (rabbit), inflammation (positron emission tomography; pig), regional inspiratory Ppl (intrabronchial balloon manometry), and stretch (electrical impedance tomography; pig) were measured. Respiratory drive was evaluated in 11 patients with ARDS.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Measurements and Main Results<\/jats:title>\n                    <jats:p>Although injury during muscle paralysis was predominantly in nondependent and middle lung regions at low (vs. high) PEEP, strong inspiratory effort increased injury (indicated by positron emission tomography and histology) in dependent lung. Stronger effort (vs. muscle paralysis) caused local overstretch and greater tidal recruitment in dependent lung, where more negative Ppl was localized and greater stretch was generated. In contrast, high PEEP minimized lung injury by more uniformly distributing negative Ppl, and lowering the magnitude of spontaneous effort (i.e., deflection in esophageal pressure observed in rabbits, pigs, and patients).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Strong effort increased dependent lung injury, where higher local lung stress and stretch was generated; effort-dependent lung injury was minimized by high PEEP in severe ARDS, which may offset need for paralysis.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1164\/rccm.201706-1244oc","type":"journal-article","created":{"date-parts":[[2018,1,11]],"date-time":"2018-01-11T11:06:24Z","timestamp":1515668784000},"page":"1285-1296","source":"Crossref","is-referenced-by-count":211,"title":["High Positive End-Expiratory Pressure Renders Spontaneous Effort Noninjurious"],"prefix":"10.1093","volume":"197","author":[{"given":"Caio C. A.","family":"Morais","sequence":"first","affiliation":[{"name":"Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Cl\u00ednicas, Faculdade de Medicina, Universidade de S\u00e3o Paulo, S\u00e3o Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yukiko","family":"Koyama","sequence":"additional","affiliation":[{"name":"Intensive Care Unit, Osaka University Hospital, Suita, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Takeshi","family":"Yoshida","sequence":"additional","affiliation":[{"name":"Intensive Care Unit, Osaka University Hospital, Suita, Japan"},{"name":"Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Glauco M.","family":"Plens","sequence":"additional","affiliation":[{"name":"Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Cl\u00ednicas, Faculdade de Medicina, Universidade de S\u00e3o Paulo, S\u00e3o Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susimeire","family":"Gomes","sequence":"additional","affiliation":[{"name":"Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Cl\u00ednicas, Faculdade de Medicina, Universidade de S\u00e3o Paulo, S\u00e3o Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cristhiano A. S.","family":"Lima","sequence":"additional","affiliation":[{"name":"Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Cl\u00ednicas, Faculdade de Medicina, Universidade de S\u00e3o Paulo, S\u00e3o Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ozires P. S.","family":"Ramos","sequence":"additional","affiliation":[{"name":"Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Cl\u00ednicas, Faculdade de Medicina, Universidade de S\u00e3o Paulo, S\u00e3o Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3790-7506","authenticated-orcid":false,"given":"S\u00e9rgio M.","family":"Pereira","sequence":"additional","affiliation":[{"name":"Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Cl\u00ednicas, Faculdade de Medicina, Universidade de S\u00e3o Paulo, S\u00e3o Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Naomasa","family":"Kawaguchi","sequence":"additional","affiliation":[{"name":"The Department of Pathology, School of Allied Health Sciences, Osaka University Graduate School of Medicine, Suita, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hirofumi","family":"Yamamoto","sequence":"additional","affiliation":[{"name":"The Department of Pathology, School of Allied Health Sciences, Osaka University Graduate School of Medicine, Suita, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Akinori","family":"Uchiyama","sequence":"additional","affiliation":[{"name":"Intensive Care Unit, Osaka University Hospital, Suita, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jo\u00e3o B.","family":"Borges","sequence":"additional","affiliation":[{"name":"Hedenstierna Laboratory, Department of Surgical Sciences, Section of Anesthesiology & Critical Care, Uppsala University, Uppsala, Sweden; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marcos F.","family":"Vidal Melo","sequence":"additional","affiliation":[{"name":"Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9323-3222","authenticated-orcid":false,"given":"Mauro R.","family":"Tucci","sequence":"additional","affiliation":[{"name":"Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Cl\u00ednicas, Faculdade de Medicina, Universidade de S\u00e3o Paulo, S\u00e3o Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marcelo B. 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