ARDSnet Ventilatory Protocol and Alveolar Hyperinflation

Grasso, Salvatore; Stripoli, Tania; Michele, Michele De; Bruno, Francesco; Moschetta, Marco; Angelelli, Giuseppe; Munno, I; Ruggiero, Vincenzo; Anaclerio, Roberto; Cafarelli, Aldo; Driessen, Bernd; Fiore, Tommaso

doi:10.1164/rccm.200702-193oc

Cited by 245 publications

(169 citation statements)

References 36 publications

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“…26 Unlike in our study, however, they determined PEEP decrementally after a recruitment maneuver, which has been demonstrated to influence the evaluation of lung compliance according to the pressure-volume curve. 27,33 Grasso et al 34 found that, compared to the ARDS Network protocol, 18 in subjects with a focal pattern of loss of aeration, PEEP is lower if set according to stress index and that the application of the ARDS Network protocol 18 in- duces alveolar hyperinsufflation and increases cytokine plasma levels. The LOVs 16 study found a lower incidence of refractory hypoxemia and need for rescue therapies associated with the application of PEEP according to F IO 2 after a 40-second, 40 cm H 2 O airway pressure recruitment maneuver, compared to the ARDS Network protocol 18 without previous recruitment maneuver, although without a statistically significant difference in rates of all-cause hospital mortality or barotrauma.…”

Section: Discussionmentioning

confidence: 99%

Individualized PEEP Setting in Subjects With ARDS: A Randomized Controlled Pilot Study

et al. 2013

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BACKGROUND: Low-tidal-volume ventilation may be associated with repetitive opening and closing of terminal airways. The use of PEEP is intended to keep the alveoli open. No method of adjusting the optimal PEEP has shown to be superior or to improve clinical outcomes. We conducted a pilot study to evaluate the effect of setting an individualized level of PEEP at the highest compliance on oxygenation, multiple-organ-dysfunction, and survival in subjects with ARDS. METHODS: Subjects with ARDS ventilated with low tidal volumes and limitation of airway pressure to 30 cm H 2 O were randomized to either a compliance-guided PEEP group or an F IO 2 -guided group. RESULTS: Of the 159 patients with ARDS admitted during the study period, 70 met the inclusion criteria. Subjects in the compliance-guided group showed nonsignificant improvements in P aO 2 /F IO 2 during the first 14 days, and in 28-day mortality (20.6% vs. 38.9%, P ‫؍‬ .12). Multipleorgan-dysfunction-free days (median 6 vs 20.5 d, P ‫؍‬ .02), respiratory-failure-free days (median 7.5 vs 14.5 d, P ‫؍‬ .03), and hemodynamic-failure-free days (median 16 vs 22 d, P ‫؍‬ .04) at 28 days were significantly lower in subjects with compliance-guided setting of PEEP. CONCLUSIONS: In ARDS subjects, protective mechanical ventilation with PEEP application according to the highest compliance was associated with less organ dysfunction and a strong nonsignificant trend toward lower mortality. ClinicalTrials.gov Number NCT01119872.

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Section: Discussionmentioning

confidence: 99%

Individualized PEEP Setting in Subjects With ARDS: A Randomized Controlled Pilot Study

et al. 2013

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“…[60][61][62] PEEP/F IO 2 tables were also used in the Lung Open Ventilation study, 51 very similar to those used by the ARDS Network. In 51 subjects, Chiumello et al 17 compared the use of this table against 3 other approaches for setting PEEP: compliance, 63 stress index, 64 and esophageal manometry. 65 Lung recruitability was assessed by whole-lung CT scans taken in static conditions at 5 and 45 cm H 2 O during an end-expiratory and end-inspiratory pause.…”

Section: Gas Exchangementioning

confidence: 99%

Recruitment Maneuvers and PEEP Titration

2015

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The injurious effects of alveolar overdistention are well accepted, and there is little debate regarding the importance of pressure and volume limitation during mechanical ventilation. The role of recruitment maneuvers is more controversial. Alveolar recruitment is desirable if it can be achieved, but the potential for recruitment is variable among patients with ARDS. A stepwise recruitment maneuver, similar to an incremental PEEP titration, is favored over sustained inflation recruitment maneuvers. Many approaches to PEEP titration have been proposed, and the best method to choose the most appropriate level for an individual patient is unclear. A PEEP level should be selected that balances alveolar recruitment against overdistention. The easiest approach to select PEEP might be according to the severity of the disease: 5-10 cm H 2 O PEEP in mild ARDS, 10 -15 cm H 2 O PEEP in moderate ARDS, and 15-20 cm H 2 O PEEP in severe ARDS. Recruitment maneuvers and PEEP should be used within the context of lung protection and not just as a means of improving oxygenation.

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“…10). 30 A linear increase in pressure (constant compliance, stress index ϭ 1) suggests adequate alveolar recruitment without over-distention. If compliance worsens as the lungs are inflated (progressive decrease in compliance, upward concavity, stress index Ͼ 1), this suggests over-distention, and the recommendation is to decrease the PEEP, V T , or both.…”

Section: Stress Indexmentioning

confidence: 99%

“…The stress index is the coefficient b of a power equation 30 : P ϭ a ϫ T I b ϩ c, where the coefficient b (stress index) describes the shape of the curve. Using this equation, the stress index can be determined by curve-fitting this equation during passive constant-flow inflation (Fig.…”

Section: Stress Indexmentioning

confidence: 99%

Respiratory Mechanics in Mechanically Ventilated Patients

2014

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Respiratory mechanics refers to the expression of lung function through measures of pressure and flow. From these measurements, a variety of derived indices can be determined, such as volume, compliance, resistance, and work of breathing. Plateau pressure is a measure of end-inspiratory distending pressure. It has become increasingly appreciated that end-inspiratory transpulmonary pressure (stress) might be a better indicator of the potential for lung injury than plateau pressure alone. This has resulted in a resurgence of interest in the use of esophageal manometry in mechanically ventilated patients. End-expiratory transpulmonary pressure might also be useful to guide the RESPIRATORY CARE • NOVEMBER 2014 VOL 59 NO 11 1773 setting of PEEP to counterbalance the collapsing effects of the chest wall. The shape of the pressuretime curve might also be useful to guide the setting of PEEP (stress index). This has focused interest in the roles of stress and strain to assess the potential for lung injury during mechanical ventilation. This paper covers both basic and advanced respiratory mechanics during mechanical ventilation.

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ARDSnet Ventilatory Protocol and Alveolar Hyperinflation

Abstract: Alveolar hyperinflation in patients with focal ARDS ventilated with the ARDSnet protocol is attenuated by a physiologic approach to PEEP setting based on the stress index measurement.

Cited by 245 publications

References 36 publications

Individualized PEEP Setting in Subjects With ARDS: A Randomized Controlled Pilot Study

Individualized PEEP Setting in Subjects With ARDS: A Randomized Controlled Pilot Study

Recruitment Maneuvers and PEEP Titration

Respiratory Mechanics in Mechanically Ventilated Patients

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