J Appl Physiol 130: 1337–1344, 2021.

First published March 18, 2021; doi:10.1152/japplphysiol.01048.2020

RESEARCH ARTICLE

Acute overventilation does not cause lung damage in moderately hemorrhaged

swine
Megan B. Blackburn,1 Ian L. Hudson,1 Cassandra Rodriguez,1 Nathan Wienandt,2 and Kathy L. Ryan1
1
Tactical and Enroute Care Research Department, United States Army Institute of Surgical Research, Joint Base San Antonio-
Fort Sam Houston, San Antonio, Texas and 2Comparative Pathology Department, United States Army Institute of Surgical
Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, Texas

Abstract
Airway management is important in trauma and critically ill patients. Prolonged mechanical ventilation results in overventilation-
induced lung barotrauma, but few studies have examined the consequence of acute (1 h or less) overventilation. We hypothe-
sized that acute hyperventilation, as might inadvertently be performed in prehospital settings, would elevate systemic inflamma-
tion and cause lung damage. Female Yorkshire pigs (40–50 kg, n = 10/group) were anesthetized, instrumented for hemodynamic
measurements and blood sampling, and underwent a 25% controlled hemorrhage followed by 1 h of 1) spontaneous breathing, 2)
“normal” bag ventilation (4.8 L·min volume, 400 mL tidal volume, 12 breaths/minute), 3) bag hyperventilation (9 L·min volume,
750 mL tidal volume, 12 breaths/minute), 4) maximum hyperventilation (15 L·min volume, 750 mL tidal volume, 20 breaths/mi-
nute), or 5) mechanical ventilation. Pigs then regained consciousness and recovered for 24 h, followed by euthanasia and collec-
tion of blood and tissue samples. No level of manual ventilation had any significant impact on hemodynamic variables. Blood
markers of tissue damage and plasma cytokines were not statistically different between groups with the exception of a transient
increase in IL-1b; all values returned to baseline by 24 h. On pathological review, severity and distribution of lung edema or other
gross pathologies were not significantly different between groups. These data indicate hyperventilation causes no adverse
effects, to include inflammation and tissue damage, and that acute overventilation, as could be seen in the prehospital phase of
trauma care, does not produce evidence of adverse effects on the lungs following moderate hemorrhage.
NEW & NOTEWORTHY Appropriate airway management is essential in trauma and critically ill patients. Prolonged mechanical
ventilation can result in overventilation-induced lung barotrauma, but few studies have examined the consequence of acute
overventilation. We investigated the outcome of hemorrhage followed by 1 h of overventilation in swine. We found that acute
overventilation, as could be seen in the prehospital phase of trauma care, does not produce evidence of adverse effects on oth-
erwise healthy lungs following moderate hemorrhage.

hemorrhage; lung barotrauma; trauma; ventilation

INTRODUCTION alkalosis, and increased intracranial pressure (4), but

Severely injured patients often receive positive-pressure
ventilation before reaching definitive care (e.g., at the point
of injury or during transport) via bag-valve-mask ventila-
tion. The potential detrimental effects of positive-pressure
ventilation (PPV) on hemodynamic stability are well
known (1, 2). In contrast to spontaneous ventilation, which
decreases intrathoracic pressure and enhances venous
return via negative intrathoracic pressure, PPV increases
intrathoracic pressure, thus diminishing venous return
and cardiac output. When combined with possible hypovo-
lemia in patients with trauma due to hemorrhage, it can
become a deadly combination (3). Prolonged use of PPV,
such as during extended intensive care unit stays, can
result in barotrauma, ventilator-associated lung injury
(VALI), acute respiratory distress syndrome, respiratory
effects of acute PPV are less well understood, although
they are assumed to be detrimental (5, 6).
Endotracheal intubation and positive-pressure ventila-
tion is the gold standard of airway management, though
there are varying opinions on its use in prehospital care (7,
8). Several studies suggest there is an increased risk of
adverse outcomes associated with prehospital PPV (3, 7).
Prehospital ventilation, including via bag-valve-mask and
endotracheal intubation, delays care, is often associa-
ted with complications, and may result in significant ove-
rventilation (9). Indeed, some hypothesize that adverse
outcomes associated with endotracheal intubation are
increased as a result of hyperventilation (9, 10), and PPV
combined with hypovolemia results in decreased ve-
nous return, decreased cardiac output, and end-organ
damage (11).

Correspondence: M. B. Blackburn (megan.b.blackburn2.civ@mail.mil).

Submitted 9 December 2020 / Revised 16 February 2021 / Accepted 9 March 2021

http://www.jap.org 8750-7587/21 Published by the American Physiological Society 1337

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 ACUTE OVERVENTILATION DOES NOT CAUSE LUNG DAMAGE
Bag-valve-mask ventilation with large tidal volumes and
high ventilation rates can be associated with complications.
A standard adult-sized bag holds 1.5 L and the American
Heart Association recommends 500–600 mL and 8–10 venti-
lations/min for a minute volume of 5 L (12, 13). Traditional
approaches to mechanical ventilation use tidal volumes of
10 to 15 mL/kg and may cause stretch-induced lung injury
(14). There are limited studies investigating tidal volume and
respiration rate delivery in the prehospital setting, but data
suggest that both tidal volume and ventilation rate are often
elevated here, where situations tend to be chaotic, highly
stressful, and care is provided by those with less training.
Tidal volumes are often above “lung protective levels” and
ventilation rates well exceed the recommended 10 breaths
per minute (14–17).
PPV via endotracheal intubation in severely hemorrhaged
animals increases mortality (18). But, to date, no studies
have assessed whether acute hyperventilation causes baro-
trauma to otherwise healthy lungs that would predispose a
hemorrhaged patient to later develop acute respiratory dis-
tress or other lung morbidity. In addition, previous work
shows cytokines are clinical markers of hemorrhage and
trauma, as well as associated with varying ventilator strategies
(19–21). With that, we hypothesized that overventilation com-
bined with hemorrhage would significantly increase inflam-
matory markers and cause significant morbidity in the lungs
as compared with spontaneous breathing. Lung morbidity
was assessed 24 h following combined hemorrhage and over-
ventilation using pathological approaches and measurement
of systemic cytokine levels as an objective surrogate for sys-
temic stress.
METHODS
Research was conducted in compliance with the Animal
Welfare Act, implementing Animal Welfare Regulations
and the principles of the Guide for the Care and Use of
Laboratory Animals, Nation Research Council. The facility’s
Institutional Animal Care and Use Committee approved all
research conducted in this study. The facility where this
research was conducted is fully accredited by AAALAC.
Ventilation Validation
Tidal volumes were validated using a RespiTrainer Advance
(IngMar Medical, Pittsburgh, PA) with endotracheal tube sec-
urely in place before animal experiments began. “Normal” bag
ventilation was performed with one-handed squeezes at the
designated rate. Hyperventilation and maximum hyperventila-
tion were achieved by two-handed squeezes aimed to maxi-
mally empty the bag.
Instrumentation
Female Yorkshire pigs (40–50 kg) were induced with an
intramuscular injection of tilatamine-zolazepam (Telazol, 4–
6 mg/kg), intubated with endotracheal tubes (8 mm inter-
nal diameter), and secured on the table, set to 0 tilt, in the
supine position. During instrumentation, animals were
mechanically ventilated with positive pressure 30% O2 at 8–
10 mL/kg per breath and 8–12 breaths per minute to main-
tain an end-tidal PCO2 of 45 ± 5 mmHg. Positive end
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expiratory pressure was set to 5 cm H2O and duty cycle at
0.5. Anesthesia was provided with 1%–3% isoflurane. Urine
output was collected via Foley catheter and body tempera-
ture was monitored via a rectal probe. The animal was placed
on a warming blanket that was set to 37 C at the start of
instrumentation and was left unchanged during the experi-
ment. A pulse oximeter (Nellcor) was attached to the tongue
or cheek for measuring peripheral oxygen saturation levels
(SpO2 ), and ECG leads were attached for heart rate (HR). A
small IV catheter was placed in the marginal ear vein for an-
esthesia, the femoral artery and vein were percutaneously
cannulated for hemorrhage and blood sampling, and the ca-
rotid artery and external jugular vein cannulated for blood
pressure monitoring and Swan–Ganz catheter (Edwards
Lifesciences, Irvine, CA) for pulmonary artery pressure (PAP)
and continuous cardiac output (CO) measuring via thermo-
dilution, respectively. Once instrumented, isoflurane was
replaced with continuous intravenous infusion of midazo-
lam (0.6–2.5 mg/kg/h) and ketamine (5–30 mg/kg/h), and ani-
mals were allowed to breathe room air spontaneously. Depth
of anesthesia was monitored based on breathing pattern, he-
modynamic variables, jaw tone, and lack of a withdrawal
reflex in response to toe pinch.
Experimental Design
A 20-min baseline of hemodynamic and respiratory pa-
rameters was recorded followed by hemorrhage and 1 h of
ventilation. A 25% hemorrhage, calculated based on body
weight and the assumption of 70 mL blood/kg, was first per-
formed via computer-controlled roller pump set to 50 mL/
min hooked to the femoral artery. Five minutes posthemor-
rhage, animals were randomly assigned to one of the follow-
ing ventilation groups (n = 10/group): 1) free breathing, 2)
bag normal ventilation (4.8 L·min volume, 400 mL tidal
volume, 12 breaths/minute), 3) bag hyperventilation (9 L·min
volume, 750 mL tidal volume, 12 breaths/minute), 4) bag
maximum hyperventilation (15 L·min volume, 750 mL tidal
volume, 20 breaths/minute), or 5) mechanical ventilation
(positive pressure 30% O2 at 8–10 mL/kg per breath and 8–12
breaths per minute to maintain an end-tidal PCO2 of
45 ± 5 mmHg). Bag ventilation was performed by attaching
an adult Ambu bag on the endotracheal tube, and efforts
were made to keep inflation/deflation time constants similar
(0.5 duty cycle). Blood samples were drawn from the femo-
ral vein catheter at baseline, immediately posthemorrh-
age, and at 30 and 60 min during ventilation challenge.
Following the 1-h period of assigned ventilation, sedation
was discontinued, catheters were withdrawn, hemostasis
was created by direct pressure, and animals were allowed to
wake up before being returned to their cages for a 24-h moni-
toring interval. Additional blood samples were collected at
4 h and 24 h after completion of ventilation via vena cava
puncture.
Blood Samples
Blood samples were collected into K2 EDTA-containing
tubes and centrifuged at 5,000 g for 10 min, divided into ali-
quots, and stored at 80 C until analysis. Cytokines, to
include GM-CSF, IFNg, IL-1a, IL-1ra, IL-1b, IL-2, IL-4, IL-6, IL-
8, IL-10, IL-12, IL-18, and TNFa, were analyzed using a
 ACUTE OVERVENTILATION DOES NOT CAUSE LUNG DAMAGE

porcine-specific multiplex kit (EMD Millipore, Billerica, MA)
according to the manufacturer’s instructions.
Pathology
Following euthanasia, both lungs were excised to measure
levels of edema and perform histological analysis. The lung
wet-to-dry (W/D) weight ratio was used as an index of lung
water accumulation due to edema resulting from overventi-
lation. To measure the total amount of lung water, a lung
sample was measured immediately after its excision (wet
weight). The lung tissue was then dried in an oven at 60 C
for 7 days and reweighed as dry weight. The W/D weight ratio
was calculated by dividing the wet by the dry weight.
Separate samples were placed in 10% neutral buffered for-
malin and sectioned in 4-mm-thick slices, which were stained
with hematoxylin and eosin. Congestion severity was scored
on a 0–4 scale (0, none; 1, mild; 2, moderate; 3, marked; 4,
severe), and thrombi presence was scored as either 0 (absent)
or 1 (present) by a veterinary pathologist blinded to treat-
ment group.
Data Analysis
Data were collected continuously on a custom-designed
data acquisition system based on Labview. All hemody-
namic, respiratory, and blood values are expressed as means
± SE. Stroke volume (SV) was calculated as CO/HR. For he-
modynamic and respiratory variables, 30-s segments at each
time point were compared with a 5-min baseline period mea-
surement. Data were analyzed by t test, one-way, or two-way
ANOVA with repeated measures, as appropriate, from base-
line and control (spontaneously breathing) versus experi-
mental groups. Where significant effects were found, Tukey
post hoc tests were performed. A value of P < 0.05 identified
significant group or time effects.
RESULTS
To determine appropriate minute volumes, bag ventila-
tion studies were undertaken before animal experimenta-
tion. The currently recommended minute volume for
ventilating prehospital patients is 4–5 L (12). Given this,
we sought to replicate those values in our normally venti-
lated group of animals. Adult Ambu bags hold 1.5 L. A
complete one-handed squeeze elicited 389 ± 19 mL and a
two-handed squeeze 744 ± 64 mL; therefore, a one-handed
squeeze was used for normoventilation and two-handed
squeeze for hyperventilation and maximum hyperventila-
tion. The following approximate minute volumes were
used for study: 4.7 L (normoventilation), 9 L (hyperventila-
tion), 15 L (maximum hyperventilation), and 4 L (mechani-
cal ventilation).
Effects of hemorrhage and ventilation on hemodynamic
variables are shown in Fig. 1. As compared with baseline val-
ues, hemorrhage significantly decreased mean arterial pres-
sure (MAP; 99.5 ± 1.6 mmHg vs. 63.5 ± 2.3 mmHg), CO (7.0 ±
0.2 L/min vs. 6.2 ± 0.2 L/min), SV (70.1 ± 1.8 mL vs. 57.1 ±
2.2 mL), and PAP (15.8 ± 0.5 mmHg vs. 9.2 ± 0.4 mmHg), and
increased HR (101 ± 2.4 beats/min vs. 115 ± 3.3 beats/min), as

Spontaneous Breathing Hyperventilation

Normoventilation Maximum Hyperventilation
Mechanical Ventilation Hemorrhage
Ventilation
60 10 100

8 80 *
*#
(mL/beat)

40
(L/min)
(mmHg)

60
etCO2

6
CO

SV

20 *# 4 40

*# 2 * 20

0 0 0

150 160 25
*
140
20 *
100
(mmHg)
(mmHg)

15
(bpm)

PAP
MAP

HR

120
10
50
100
* 5

0 80 0
30 60 90 120 30 60 90 120 30 60 90 120
Time (min) Time (min) Time (min)
Figure 1. Summary data of the effects of hemorrhage and ventilation on ETCO2 , CO, SV, MAP, HR, and PAP (n = 10 animals/group). Values are means ±
SE, significant difference vs. baseline, #significant difference vs. spontaneous breathing. CO, cardiac output; HR, heart rate; MAP, mean arterial pres-
sure; PAP, pulmonary artery pressure; SV, stroke volume.

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 ACUTE OVERVENTILATION DOES NOT CAUSE LUNG DAMAGE

expected across all groups. And as expected, at the end of only spontaneously breathing and mechanically ventilated
hemorrhage, there were slight decreases in pH and increases animals, whereas creatine kinase was significantly elevated
in lactate. There was no difference in these responses to in normoventilation, maximum hyperventilation, and mec-
hemorrhage across groups. hanically ventilated animals at 24 h compared with
Normoventilation, hyperventilation, and maximum hyp- baseline.
erventilation significantly decreased ETCO2 . A significant Proinflammatory and anti-inflammatory cytokine levels
increase in heart rate compared with baseline was exhibited in plasma were quantified across time (Fig. 3) and compared
in those that underwent maximum hyperventilation and with levels in spontaneously breathing control animals.
mechanical ventilation, but there were no significant hemo- Expression levels of IL-1b and IL-2 were significantly ele-
dynamic differences observed between ventilation groups vated above spontaneous breathing controls at 4 h posthe-
(Fig. 1). There were significant changes in blood gases during morrhage in the maximally hyperventilated group; there
the course of ventilation, but all returned to baseline by 24 h were no other significant changes and values returned to
with the exception of pH (Fig. 2). PCO2 was significantly baseline by 24 h. Although IL-4 expression trended upward
impacted by ventilation, decreasing from baseline in hyper- in the maximum hyperventilation group at 4 h, it was not
ventilation and maximum hyperventilation groups and statistically elevated as compared with controls and returned
increasing in spontaneously breathing and mechanically to baseline levels by 24 h. IFNg, IL-1a, IL-1ra, IL-6, IL-8, IL-10,
ventilated animals. Likewise, hyperventilation and maxi- IL-12, IL-18, and TNF-a had no significant changes. GM-CSF
mum hyperventilation decreased bicarbonate levels. Blood was below detectable levels.
pH was significantly changed from baseline during the 1 h of Lung W/D weight ratio was comparable across all groups
ventilation; pH was decreased in spontaneously breathing at 24 h. Likewise, there was no significant difference in con-
and mechanically ventilated swine but was increased by gestion severity or the presence of thrombi (Fig. 4).
maximum hyperventilation. Maximum hyperventilation sig-
nificantly increased pH compared with spontaneous breath- DISCUSSION
ing. pH remained statistically elevated in all groups at 24 h,
except for the normoventilation group. Lactate was also sig- In this study, we sought to mimic a prehospital trauma
nificantly elevated in all groups but returned to baseline lev- scenario to test whether acute overventilation increases mor-
els by 24 h. Alanine aminotransferase was elevated at 24 h in bidity following hemorrhage. We found no negative side

Spontaneous Breathing Hyperventilation

Normoventilation Maximum Hyperventilation
Mechanical Ventilation

80 35 7.6

40
* * *# *
30
7.5
*#
(mmol/L)
(mmHg)

HCO3
pCO2

pH

60 7.4
25
20 *# *# 7.3
#*
20 * #* 7.2
* *
0
Alanine Aminotransferase

15 150 25000
*
*
Creatine Kinase

20000
10 100
(mmol/L)
Lactate

(U/L)

15000
(U/L)

10000
5 50
5000

0 0 0
Baseline

Hemorrhage

30” Ventilation

60” Ventilation

4h

24 h

Baseline

Hemorrhage

30” Ventilation

60” Ventilation

4h

24 h

Baseline

Hemorrhage

30” Ventilation

60” Ventilation

4h

24 h

Figure 2. Summary data of the effects of hemorrhage and ventilation on PCO2,HCO3 , pH, lactate, alanine aminotransferase, and creatine kinase (n = 10
animals/group). Values are means ± SE, significant difference vs. baseline, #significant difference vs. spontaneous breathing.

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 ACUTE OVERVENTILATION DOES NOT CAUSE LUNG DAMAGE

Spontaneous Breathing Hyperventilation

Normoventilation Maximum Hyperventilation
Mechanical Ventilation

0.1 0.10 0.15

# #
0.05
0.0 0.10
'lL-1E
ng/mL

ng/mL
ng/mL

'lL-6
'lL-2
0.00

-0.1 0.05
-0.05

-0.2 -0.10 0.00

0.03 0.2 0.03

0.02 0.02
0.1
0.01
'TNF-D

ng/mL
ng/mL

0.01
ng/mL

'lL-8
'lL-4

0.0 0.00
0.00
-0.01
-0.1
-0.01 -0.02

-0.02 -0.2 -0.03

1h 4h 24 h 1h 4h 24 h 1h 4h 24 h
Figure 3. Summary data of the change in cytokine levels from baseline 1 h, 4 h, and 24 h from the start of the experiment (n = 10 animals/group). #signifi-
cant difference vs. spontaneous breathing.

effects associated with 1 h of overventilation following hem-
orrhage, to include hemodynamic changes, systemic inflam-
matory markers, or lung tissue damage. This indicates that
hyperventilation, as could be seen in the prehospital phase
of care, does not adversely affect hemorrhaged casualties
with otherwise healthy lungs.
Approximately 5% of trauma casualties receive prehospi-
tal airway management (22). We replicated the currently rec-
ommended minute volume of 4–5 L with a one-handed
squeeze of an adult Ambu bag, which holds 1.5 L. To produce
hyperventilation, we expelled as much air from the Ambu
bag as possible with a two-handed squeeze, which resulted
in minute volumes of 9.4 L and 15.6 L, for hyperventilation
and maximum hyperventilation, respectively. These vol-
umes are similar to those achieved in previous studies exam-
ining proper grip during bag-valve-mask ventilation (23) and
represent plausible volumes during rigorous ventilation. We
opted to include groups with varying volumes and rates to
capture any differences that may have arisen as a result of
the changing rate, given that a higher rate did not allow time
for the lungs to fully deflate. The maximum respiration rate
used, 20 breaths/min, was similar to previous reports on pre-
hospital bag valve mask ventilation (17). In this study, we
used room air for 1 h of ventilation, but to understand the
full scope of prehospital positive pressure ventilation, a
future study will need to examine the effects of using 100%
O2 as hyperoxia may have deleterious effects, as shown in
patients with traumatic brain injury (24). We opted for room
air, as far-forward providers do not often have access to sig-
nificant amounts of 100% oxygen. In addition, there is
debate about the use of adult versus pediatric Ambu bags
(16, 25) to help offset overventilation, but given that there is
no mandate for use of pediatric bags in the prehospital
space, we felt that use of an adult bag was most pertinent.
Up to 60,000 people die from hemorrhage per year in the
United States (26), and it is the leading cause of potentially
survivable death on the battlefield (27). It was, therefore, im-
portant to include hemorrhage as part of the insult in combi-
nation with positive pressure ventilation to simulate a
prehospital trauma scenario. Previous studies show that
hemorrhage and positive pressure ventilation independently
affect hemodynamic variables but did not assess damage to
the lungs (28, 29). Given this, we anticipated an additive neg-
ative effect on hemodynamics in the hyperventilation and
maximum hyperventilation groups. In contrast, although
hemorrhage slightly decreased CO, there was no significant
further decrease during positive pressure ventilation in any
of the groups. This is inconsistent with previous evidence
that positive pressure ventilation in combination with severe
hemorrhagic shock increased mortality compared with
spontaneous breathing (11). One difference between these
studies is the level of hemorrhagic shock, as the previous
investigators allowed animals to exsanguinate (11). Our study
simulated casualties in level II hemorrhagic shock based on
percent blood loss (26), a moderate hemorrhage that allowed
animals to survive so that the extent of barotrauma could be
assessed at a later time, to maximize the possibility that any
pathology produced by the ventilation strategy would be evi-
dent. It is unknown what impact greater blood loss would
have on our model. In addition, female swine were used for
this study and sex hormones play a significant role in physi-
ological responses including respiratory and cardiovascular
systems (30). Although females have a lower tolerance to
blood loss (31), it is unknown how sex differences impact

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 ACUTE OVERVENTILATION DOES NOT CAUSE LUNG DAMAGE

with human posttraumatic levels, this is interesting, as no

Spontaneous Breathing Hyperventilation
significant effect of trauma and hemorrhage was previously
Normoventilation Maximum Hyperventilation reported (33). Similarly, IL-6 and IL-8, reported to correlate
with injury severity score and orthopedic trauma, were tran-
Mechanical Ventilation siently, but nonsignificantly, elevated among our model and
6.5
returned to near-baseline in all but the hyperventilation
group. In aggregate, the possibility that unnecessary hyper-
Wet:Dry Lung Weight (g)

6.0 ventilation could contribute to the proinflammatory state

posttrauma suggests it should be avoided. Conversely, IL-4,
5.5 an anti-inflammatory cytokine, was also found in our study
to be somewhat increased in the maximum hyperventilation
5.0 group, though nonsignificantly so. Although IL-4 was found
to be decreased in human patients immediately following
4.5
trauma, and an increase could be compensatory for the early
proinflammatory environment following trauma (34), the
4.0
net effect of hyperventilation in patients with trauma with-
out traumatic brain injury has not been established. Given
2.5 hyperventilation may be harmful to patients with trauma
2.0 (35, 36), and in conjunction with our own findings of possible
Congestion Severity

1.5
proinflammatory effects of hyperventilation, we are unable
to foresee a net benefit of hyperventilation in pursuit of a
1.0
very modest increase in IL-4.
0.5 One limitation of this study is that the animals were intu-
0.0
bated throughout the experimental phase and intrathoracic
pressure was not measured. Therefore, the influx of air into
-0.5
the stomach that might normally occur during bag-valve-
-1.0 mask ventilation was prevented. It is possible that this
impacted our outcome variables but given the swine anat-
1.5 omy, achieving a proper seal around the mouth would not
have been possible. In addition, animals were recovered for
1.0 only 24 h. Given that all outcomes measured, with the excep-
Thrombi Presence

tion of IL-1b, returned to baseline or were not statistically dif-

0.5
0.0
-0.5
-1.0
Figure 4. Summary of pulmonary pathological findings including: wet to dry
lung weight ratio, congestion severity, and thrombi presence (n = 10 animals/
group). There were no significant differences between any of the groups.
overventilation induced injuries. To our knowledge, this is
the first study to investigate whether positive pressure venti-
lation produces overt or incipient damage to the lung follow-
ing hemorrhage.
Given the involvement of various cytokines in the inflam-
matory cascade following trauma that can precipitate multi-
organ system failure, it was important to explore the relative
impact hyperventilation may have on their levels as surro-
gates of generalized systemic stress, independent of the
trauma itself as a means to extrapolate what independent
but contributory effect inadvertent hyperventilation might
have. We identified a significant increase in IL-1b among the
maximum hyperventilation group beyond what has been
generally seen in human trauma (32), suggesting that a
hyperventilatory period could impose an excess inflamma-
tory burden on a casualty. Other proinflammatory cytokines,
IL-2 and TNF-a, were also elevated transiently, though were
not significantly different at the 24-h point; when compared
ferent than controls, it is unlikely that a prolonged time
point would have provided additional insights. As previously
noted, we chose a moderate hemorrhage in order that ani-
mals could be recovered without resuscitation; larger hemor-
rhage volumes could amplify ventilation effects on the lung.
In addition, iatrogenic effects of aggressive resuscitation
could produce harmful effects on the lung (37) and increase
the inflammatory response. Finally, hemorrhage is just one
of many potential insults that trauma casualties who require
prehospital positive pressure ventilation may experience;
emerging evidence from our laboratory suggests that even
mild/moderate traumatic injury compounds end-organ dys-
function (unpublished data). With that, it is unknown how
direct trauma to the lungs, as may be seen in a motor vehicle
crash or blast injury, may impact ventilation-induced baro-
trauma and downstream inflammatory cascades. Previous
data shows that VALI can occur in otherwise healthy lungs
subject to overventilation but is significantly more likely to
occur in those with previous injuries to the lung (38). Further
studies are needed to determine the effects acute hyperven-
tilation may have on injured lung tissue.
Our findings suggest that in the specific prehospital set-
ting wherein patients receive room air positive pressure ven-
tilation, that short-term overventilation by either increased
tidal volume or respiration rate per se does not cause pro-
longed negative outcomes on the lung, though this hyper-
ventilation may increase short-term systemic inflammation
and stress. Neither the pathology results nor the cytokine anal-
ysis yielded evidence of barotrauma that would predispose to

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 ACUTE OVERVENTILATION DOES NOT CAUSE LUNG DAMAGE
the later development of acute respiratory distress following
moderate hemorrhage.
ACKNOWLEDGMENTS
We acknowledge Gary Muniz for technical assistance and the
US Army Institute of Surgical Research Veterinary Support
Branch, to include Antoinette Davidson, BJ Malone, Belinda
Meyers, and Breanna Estrada.
GRANTS
This work was supported by funding from the Medical
Research and Materiel Command, Tactical Combat Casualty Care
Research Program and the U.S. Army Medical Research and
Development Command (MRDC) Grant D_003_2017_USAISR (to
M.B.B.)
DISCLAIMERS
The views expressed in this article are those of the authors
and do not reflect the official policy or position of the U.S. Army
Medical Department, Department of the Army, DoD, or the U.S.
Government.
DISCLOSURES
No conflicts of interest, financial or otherwise, are declared by
the authors.
AUTHOR CONTRIBUTIONS
M.B.B. conceived and designed research; M.B.B., I.L.H., and
C.R. performed experiments; M.B.B., C.R., and N.W. analyzed
data; M.B.B. and I.L.H. interpreted results of experiments; M.B.B.
prepared figures; M.B.B. drafted manuscript; M.B.B., I.L.H., C.R.,
N.W., and K.L.R. edited and revised manuscript; M.B.B., I.L.H., C.R.,
N.W., and K.L.R. approved final version of manuscript.
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