Low Tidal Volume Ventilation in Patients without Acute Respiratory Distress Syndrome: A Paradigm Shift in Mechanical Ventilation

Abstract

Protective ventilation with low tidal volume has been shown to reduce morbidity and mortality in patients suffering from acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Low tidal volume ventilation is associated with particular clinical challenges and is therefore often underutilized as a therapeutic option in clinical practice. Despite some potential difficulties, data have been published examining the application of protective ventilation in patients without lung injury. We will briefly review the physiologic rationale for low tidal volume ventilation and explore the current evidence for protective ventilation in patients without lung injury. In addition, we will explore some of the potential reasons for its underuse and provide strategies to overcome some of the associated clinical challenges.

Changing the Focus in Acute Respiratory Distress Syndrome

“…Recently, Serpa Neto et al (10) summarized the literature about the use of lung protective ventilation strategy in patients without ARDS and found evidence that a ventilation strategy using lower tidal volumes was associated with lower risk of developing ARDS in these patients. These findings are in line with many other studies pubhshed in the last years confirming the role of low tidal volume ventüation in the prevention of ARDS (11,12).…”

Preemptive Application of Airway Pressure Release Ventilation Prevents Development of Acute Respiratory Distress Syndrome in a Rat Traumatic Hemorrhagic Shock Model

“…increased permeability, alveolar edema, surfactant deactivation and alveolar instability). We chose the ventilator settings in the VC group to be similar to those often used in surgery patients [12–15] since our model of T/HS simulates the trauma patient who would often undergo surgery and subsequently be treated in the Surgical Intensive Care Unit (SICU). However, it is very possible that preemptive application of VC with a low Vt and higher PEEP might also prevent ARDS development, similar to APRV.…”

“…We chose the Vt and PEEP settings for the VC group to match the Vt and PEEP routinely delivered to patients undergoing surgery, which we felt would be most appropriate for our T/HS rat model [12–15]. These studies show that surgery patients are typically ventilated with Vt of 10 or greater with zero end expiratory pressure (ZEEP).…”

Open Lung in Lateral Decubitus With Differential Selective Positive End-Expiratory Pressure in an Experimental Model of Early Acute Respiratory Distress Syndrome*

“…The extended time spent at the upper pressure combined with the very brief release phase stabilized patent alveoli, reducing atelectrauma secondary to alveolar recruitment/derecruitment or repetitive alveolar closure and expansion. A decrease in ventilation heterogeneity was also argued to be the main mediator of beneficial effects in other studies, reducing volutrauma and atelectrauma (33)(34)(35)(36)(37).…”