Inverse ratio ventilation compared with PEEP in adult respiratory failure

Cole, A. G. H.; Weller, Santiago; Sykes, M.K.

doi:10.1007/bf00256258

Cited by 166 publications

(47 citation statements)

References 15 publications

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“…In the mid-1980s there were reports of improved oxygenation with pressure controlled inverse-ratio ventilation (PCIRV), [61][62][63][64][65] and for some time in the decade thereafter there was enthusiasm for this method. With PCIRV, an inspiratory time greater than the expiratory time is used to increase mean airway pressure and thus improve arterial oxygenation.…”

Section: Prolonged Inspiratory Time and Inverse Inspiratory-expiratormentioning

confidence: 99%

Approaches to Conventional Mechanical Ventilation of the Patient With Acute Respiratory Distress Syndrome

Hess

2011

Respir Care

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To minimize ventilator-induced lung injury, attention should be directed toward avoidance of alveolar over-distention and cyclical opening and closure of alveoli. The most impressive study of mechanical ventilation to date is the Acute Respiratory Distress Syndrome (ARDS) Network study of higher versus lower tidal volume (V T ), which reported a reduction in mortality from 39.8% to 31.0% with 6 mL/kg ideal body weight rather than 12 mL/kg ideal body weight (number-neededto-treat of 12 patients). To achieve optimal lung protection, the lowest plateau pressure and V T possible should be selected. What is most important is limitation of V T and alveolar distending pressure, regardless of the mode set on the ventilator. Accumulating observational evidence suggests that V T should be limited in all mechanically ventilated patients-even those who do not have ALI/ARDS. Evidence does not support the use of pressure controlled inverse-ratio ventilation. Although zero PEEP is probably injurious, an area of considerable controversy is the optimal setting of PEEP. Available evidence does not support the use of higher PEEP, compared to lower PEEP, in unselected patients with acute lung injury (ALI)/ARDS. However, results of a metaanalysis using individual patients from 3 randomized controlled trials suggest that higher PEEP should be used for ARDS, whereas lower PEEP may be more appropriate in patients with ALI. PEEP should be set to maximize alveolar recruitment while avoiding over-distention. Many approaches for setting PEEP have been described, but evidence is lacking that any one approach is superior to any other. In most, if not all, cases of ALI/ARDS, conventional ventilation strategies can be used effectively to provide lung-protective ventilation strategies.

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Section: Prolonged Inspiratory Time and Inverse Inspiratory-expiratormentioning

confidence: 99%

Approaches to Conventional Mechanical Ventilation of the Patient With Acute Respiratory Distress Syndrome

Hess

2011

Respir Care

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“…IRV has since also been proposed for ARDS lungs [38][39][40][41][42]. The possible advantages in lungs with considerable ventilation/perfusion mismatching are: 1) the prolonged inspiration ensures a more homogeneous ventilation and keeps collapsible alveoli open for a longer period of time; and 2) during the short expiration slower compartments will not exhale completely, they remain distended by PEEPi (regional or "individual" trapped volume) which is, indeed, intended.…”

Section: Variation Of the Inspiration:expiration (I:e) Ratiomentioning

confidence: 99%

New strategies in mechanical ventilation for acute lung injury

Burchardi¹

1996

Eur Respir J

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In the fluid-filled lungs of early adult respiratory distress syndrome (ARDS) the dependent parts are compressed and atelectatic; whereas, the nondependent areas remain aerated and functional. Ventilating these considerably restricted lungs carries the risk of overinflation and ventilatory-induced lung injury (baro-volutrauma).The consequences for adjusting mechanical ventilation are: 1) reducing tidal volumes in order to avoid alveolar hyperinflation and excessive alveolar pressures; 2) considering permissive hypercapnia if adequate CO 2 elimination cannot be maintained; 3) keeping open the unstable alveoli by positive end-expiratory pressure (PEEP) (external or intrinsic). However, the large variations in regional lung compliance make it improbable that an optimal external PEEP level beneficial for the whole lung will be found; 4) using intrinsic PEEP in the inverse ratio ventilation (IRV) mode which varies with differences in regional ventilatory kinetics. No clinical study has yet convincingly demonstrated the benefit of IRV compared to conventional ventilation, controlled clinical long-term trials are not yet available; and 5) using superimposed spontaneous breathing which may be considerably more effective in opening up collapsed alveoli, combined with intentional intrinsic PEEP this is achieved in airway pressure release ventilation (APRV).Other new principles of mechanical ventilation, such as "proportional assist ventilation" or "tracheal gas insufflation" must still be considered as experimental. Eur Respir J., 1996Respir J., , 9, 1063 SERIES 'CLINICAL PHYSIOLOGY IN RESPIRATORY INTENSIVE CARE' Edited by A. Rossi and C. RoussosMechanical ventilation and ventilatory support techniques have undergone an impressive evolution within the last 10 yrs. This was due to considerable technical development rather than a radical change in our pathophysiological knowledge. Today, a variety of new techniques are available which facilitate new ventilatory strategies. In this review, only strategies for nonobstructive acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) will be presented and discussed. Strategies for chronic obstructive airways diseases (COPD) differ considerably; they will not be mentioned in this connection. Pathophysiological basisIn ALI and ARDS, (the American-European Consensus Conference on ARDS [1] changed the former expression "adult respiratory distress syndrome" into "acute respiratory distress syndrome", since ARDS is not limited to adults), the hallmark is a critical increase of pulmonary membrane permeability. This can happen by two different pathways: directly by lesion of lung cells; and indirectly as the result of an acute systemic inflammatory reaction (cellular and humoral effects). This results in a bilateral pulmonary interstitial and intra-alveolar (noncardiogenic) oedema.As a consequence, alveoli are compressed or flooded, and the surface for pulmonary gas exchange is considerably reduced by multiple atelectases. In this way, venous admixture and intr...

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“…Am J Respir Crit Care Med Vol 149. pp [1550][1551][1552][1553][1554][1555][1556]1994 with prolonged time constants may improve the overall gas exchange (8). This allows a reduction of both the inspiratory volume as well as the applied external PEEP with consequently lower peak airway pressure (Paw max ) .…”

mentioning

confidence: 99%

“…IRV with low PEEP Cl, 8,10) as well as APRV (11) are ventilatory modes, which can recruit collapsed alveoli and improve oxygenation. Other studies (12) could not demonstrate a significant improvement especially with regard to oxygen delivery (13).…”

mentioning

confidence: 99%

Long-term effects of two different ventilatory modes on oxygenation in acute lung injury. Comparison of airway pressure release ventilation and volume-controlled inverse ratio ventilation.

Sydow

Burchardi²,

Ephraim³

et al. 1994

Am J Respir Crit Care Med

211

101

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A total of 18 patients with acute lung injury (ALI) were sequentially ventilated with two different modes of mechanical ventilation, each applied for a period of 24 h: (1) volume-controlled inverse ratio ventilation (VC-IRV), (2) airway pressure release ventilation (APRV). The individual sequence of both ventilatory modes was randomized. Ventilatory minute volume was adjusted for a PaCO2 of 35 to 45 mm Hg at the beginning of the study during the first ventilatory mode and then kept constant within preset limits. Hemodynamic variables were stable and similar during the 24-h periods of VC-IRV and APRV as well. Despite the lower sedation and spontaneous breathing during APRV, oxygen uptake was similar during both ventilatory modes. During the 24-h period of VC-IRV there was no relevant change of either airway pressures, alveolo-arterial O2 tension difference (AaDO2)/fraction of inspired oxygen (FIO2) or venous admixture. In contrast, peak airway pressures (Pawmax) during APRV were significantly lower (about 30%; p < 0.01), and decreased further within 24 h (p < 0.05). During APRV AaDO2/FIO2 and venous admixture improved significantly with time after more than 8 h (AaDO2/FIO2: 487 versus 414 mm Hg; p < 0.01; venous admixture: 20.6 versus 13.9%; p < 0.01; medians of onset versus end). The improvement was significantly different between both ventilatory modes (p < 0.01). We conclude that this indicates a progressive alveolar recruitment over time during ventilation with APRV.(ABSTRACT TRUNCATED AT 250 WORDS)

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Inverse ratio ventilation compared with PEEP in adult respiratory failure

Cited by 166 publications

References 15 publications

Approaches to Conventional Mechanical Ventilation of the Patient With Acute Respiratory Distress Syndrome

Approaches to Conventional Mechanical Ventilation of the Patient With Acute Respiratory Distress Syndrome

New strategies in mechanical ventilation for acute lung injury

Long-term effects of two different ventilatory modes on oxygenation in acute lung injury. Comparison of airway pressure release ventilation and volume-controlled inverse ratio ventilation.

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