Chest
Postgraduate Education Corner: Contemporary Reviews in Critical Care MedicineMechanical Ventilation in ARDS: A State-of-the-Art Review
Section snippets
Low Tidal Volume Ventilation
Early interest in low tidal volume ventilation was prompted by animal studies3, 4showing that ventilation with large tidal volumes and high inspiratory pressures resulted in the development of ALI characterized by hyaline membranes and inflammatory infiltrates. While tidal volumes of 10 to 15 mL/kg had traditionally been used in the majority of patients with respiratory failure,5it was recognized in the mid-1980s that ARDS resulted in a significant reduction in the amount of normally aerated
High PEEP and Alveolar Recruitment
PEEP is an essential component of mechanical ventilation for patients with ARDS that should be utilized to increase the proportion of nonaerated lung, resulting in improved oxygenation. Traditionally, PEEP values of 5 to 12 cm H2O have been used in the ventilation of patients with ARDS.34However, it currently remains unclear whether these values are ideal since randomized trials14, 35, 36have not shown that higher levels of PEEP lead to a reduction in mortality rate.
Early observations that PEEP
Prone Positioning
Mechanical ventilation in the prone position was first proposed in 1974 by Bryan,40who suggested that the procedure would result in better expansion of the dorsal lung regions, thus improving oxygenation. Shortly thereafter, two nonrandomized studies41, 42reported the successful use of prone positioning as an adjunct to mechanical ventilation for the treatment of ARDS, with patients experiencing improved oxygenation. In the 3 decades following these initial reports, interest in prone
Alternative Modes/Methods of Mechanical Ventilation
Both large trials conducted by the ARDS Network utilized the volume assist/control mode of ventilation. In fact, this was the only mode of ventilation used in each of the three randomized controlled trials of ARDS in which the intervention significantly reduced mortality.10, 14, 35Although the efficacy of low tidal volume ventilation is not necessarily contingent on the use of the volume assist/control mode of ventilation, it continues to be the recommended mode in the general population of
Liberation From Mechanical Ventilation
As the majority of patients who are mechanically ventilated for acute respiratory failure spend approximately two thirds of their time on the ventilator in the “weaning” period,34a systematic, evidence-based approach to liberating ARDS patients from mechanical ventilation is an essential component of their care. This approach should be protocol-directed, and a daily spontaneous breathing trial should be the central component of that protocol.
Several randomized controlled trials60, 61, 62have
Conclusion
In the management of patients with ARDS, low tidal volume ventilation (ie, ≤ 6 mL/kg predicted body weight) with the maintenance of plateau pressures of < 30 cm H2O, when possible, remains the standard of care as it is the only method of mechanical ventilation that has been proven to reduce the mortality rate. While modifications of these parameters could result in even better outcomes than those observed in the ARMA and ALVEOLI trials (Fig 2), randomized controlled trials should be performed
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2019, Annual Reviews in ControlCitation Excerpt :Mechanical ventilation (MV) is a core life-support therapy for patients suffering from respiratory failure or acute respiratory distress syndrome (ARDS) (de Matos et al., 2012; Girard & Bernard, 2007; Herridge et al., 2003; Lorx et al., 2010; Petrucci & De Feo, 2013; Slutsky, 1993; Slutsky & Tremblay, 1998; Sundaresan et al., 2009).
The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.