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Effect of positive pressure ventilation on lymphatic flow in pediatric patients

Journal of Perinatology volume 43, page 1082 (2023)Cite this article

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We read with great interest the excellent article by Kahn et al. [1]. The article addresses a problem that is almost constantly overlooked and whose patho-physiological aspects are often completely ignored. We agree with the Authors that the central venous pressure is the cornerstone for understanding the dynamics of the lymphatic flow and above all the possibility of (pulmonary) lymph drainage.

We just would like to make one observation related to this very important study. Pulmonary lymphatic drainage follows different ways [2]. The parietal pleura is responsible for the drainage of the pleural fluid both physiologically and in the case, for example, of chylothorax. The draining capacity of the parietal pleura can be increased several-fold compared to baseline. An imbalance obviously generates pleural effusion. The drainage of the lung parenchyma is different; the visceral pleura is almost completely impermeable; drainage of pulmonary interstitial fluid occurs through the lung parenchymal interstitial lymphatic network. Therefore, applying a high PEEP (and certainly median PEEP 17.5 mmHg is significant) can have a positive effect if it acts as a sort of squeezing on the “flooded” parenchyma, whose resistance partially compensates for the applied PEEP, but if applied to a well compliant lung it may actually result in the collapse of part of the parenchyma but possibly of the function of the parietal pleura also. We fully agree that it is central venous pressure that regulates lymphatic flow, as the Authors have admirably demonstrated, but we believe the important point is not so much the PEEP itself, but rather the balance between applied PEEP and the patient’s pulmonary condition.

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References

  1. Khan S, Smith CL, Pinto EM, Taha DK, Gibbs KA, Rosenblatt SA, et al. Effect of positive pressure ventilation on lymphatic flow in pediatric patients. J Perinatol. 2022. https://doi.org/10.1038/s41372-022-01563-7.

  2. Bellini C, Ergaz Z, Boccardo F, Bellini T, Campisi C, Bonioli E, et al. Dynamics of pleural fluid effusion and chylothorax in the fetus and newborn: role of the lymphatic system. Lymphology. 2013;46:75–84.

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  3. Johnson SA, Vander Straten MC, Parellada JA, Schnakenberg W, Gest AL. Thoracic duct function in fetal, newborn, and adult sheep. Lymphology. 1996;29:50–56.

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  4. Bellini C, Boccardo F, Bonioli E, Campisi C. Lymphodynamics in the fetus and newborn. Lymphology. 2006;39:110–7.

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Authors and Affiliations

  1. Neonatal Intensive Care Unit, Department Mother&Child, IRCCS Giannina Gaslini, Genoa, Italy

    Carlo Bellini

  2. Department of Surgery, Unit of Lymphatic Surgery and Microsurgery, San Martino Hospital, University of Genoa, Genoa, Italy

    Francesco Boccardo

  3. Emergency Department, IRCCS Giannina Gaslini Institute, Genoa, Italy

    Tommaso Bellini

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  1. Carlo Bellini
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  2. Francesco Boccardo
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  3. Tommaso Bellini
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All authors have reviewed the manuscript, contributed to each version of the draft, and approved the final version of the manuscript.

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Correspondence to Carlo Bellini.

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Bellini, C., Boccardo, F. & Bellini, T. Effect of positive pressure ventilation on lymphatic flow in pediatric patients. J Perinatol 43, 1082 (2023). https://doi.org/10.1038/s41372-023-01651-2

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