Maximal Recruitment Open Lung Ventilation in Acute Respiratory Distress Syndrome (PHARLAP). A Phase II, Multicenter Randomized Controlled Clinical Trial

Hodgson, Carol; Cooper, DJ; Arabi, Yaseen M.; King, Victoria; Bersten, Andrew D.; Bihari, Shailesh; Brickell, Kathy; Davies, Andrew R.; Fahey, Ciara; Fraser, John F.; McGuinness, Shay; Murray, Lynne; Parke, Rachael; Paul, Eldho; Tuxen, David V.; Vallance, Shirley; Young, Meredith; Nichol, Alistair

doi:10.1164/rccm.201901-0109oc

Cited by 96 publications

(100 citation statements)

References 27 publications

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“…Traditional RMs are described as prolonged inspiratory holds for a set duration of time on higher levels of CPAP, most commonly 35-40 cm H 2 O for 40 s [93,104,128,129]. Incremental PEEP titration RMs are described as incremental increases in PEEP from 25 to 35 to 45 cm H 2 0 for 1-2 min each [130][131][132][133].…”

Section: Rationalementioning

confidence: 99%

Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)

et al. 2020

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Background: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed. Methods:We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations. Results:The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which 4 are best practice statements, 9 are strong recommendations, and 35 are weak recommendations. No recommendation was provided for 6 questions. The topics were: (1) infection control, (2) laboratory diagnosis and specimens, (3) hemodynamic support, (4) ventilatory support, and (5) COVID-19 therapy.Recommendation 9. For the acute resuscitation of adults with COVID-19 and shock, we suggest using a conservative over a liberal fluid strategy. Weak recommendation, low-quality evidence.

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Section: Rationalementioning

confidence: 99%

Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)

et al. 2020

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“…Positive end-expiratory pressure (PEEP) is added in an attempt to stabilize the alveoli in between (Acute Respiratory Distress Syndrome Network, 2000). High-frequency oscillatory ventilation (HFOV) and lung recruitment maneuvers (LRMs) have been shown ineffective in reducing ARDS mortality (Brower et al, 2004;Meade et al, 2008;Mercat et al, 2008;Ferguson et al, 2013;Young et al, 2013;Cavalcanti et al, 2017;Hodgson et al, 2019). Prone position has been shown effective at reducing mortality (Guerin et al, 2013) by a mechanism of reducing regional alveolar strain and inflammation (Motta-Ribeiro et al, 2018;Xin et al, 2018).…”

Section: Problems With Protecting the Baby Lungmentioning

confidence: 99%

“…However, multiple RCTs testing the OLA in ARDS patients have failed to show significant benefits over standard of care (Brower et al, 2004;Meade et al, 2008;Mercat et al, 2008;Cavalcanti et al, 2017;Hodgson et al, 2019). Reasons for these failures include the following: (1) timing of OLA application [early (Borges et al, 2006) vs. late (Gattinoni et al, 2006)] (2) onesize-fits-all RM strategies, (3) PEEP set inappropriately to keep the recruited lung open, (4) recruiting pressures insufficient to open all of the lung, (5) a patient population of responders (lung recruits) and non-responders (lung does not recruit) (Gattinoni et al, 2006), and (6) application of OLA not as a continuous treatment but rather as a one-time event with a long time period before a second application or with no second application at all (Goligher et al, 2017;Lu et al, 2017;Bhattacharjee et al, 2018;Cui et al, 2019;Hodgson et al, 2019;Kang et al, 2019;van der Zee and Gommers, 2019;Zheng et al, 2019). Most (Bhattacharjee et al, 2018;Cui et al, 2019;Hodgson et al, 2019;Kang et al, 2019;Zheng et al, 2019) but not all (Goligher et al, 2017;Lu et al, 2017) meta-analyses have shown no decrease in ARDS-related mortality associated with the OLA.…”

Section: Open Lung Approach (Ola) As a Protective Strategymentioning

confidence: 99%

“…Of course the strategy of "casting" the broken lung open until it heals would be clinically effective only with a ventilation strategy that could perform such a feat (Nieman et al, 2018). Unfortunately, the current OLA strategies have not been shown effective at opening and stabilizing the lung (Bhattacharjee et al, 2018;Cui et al, 2019;Hodgson et al, 2019;Kang et al, 2019;Zheng et al, 2019), and the recent ART trial showed an increase in FIGURE 10 | Left -Subpleural alveoli seen using in vivo microscopy in a rat hemorrhagic shock-induced ARDS model ventilated with volume cycled ventilation (VC; A,B) or airway pressure release ventilation (APRV) using the time controlled adaptive ventilation (TCAV) method (APRV; C,D). Individual alveoli are shown by arrows.…”

Section: Eliminating Constraints Of Ventilating the Acutely Injured Lungmentioning

confidence: 99%

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A Physiologically Informed Strategy to Effectively Open, Stabilize, and Protect the Acutely Injured Lung

et al. 2020

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Acute respiratory distress syndrome (ARDS) causes a heterogeneous lung injury and remains a serious medical problem, with one of the only treatments being supportive care in the form of mechanical ventilation. It is very difficult, however, to mechanically ventilate the heterogeneously damaged lung without causing secondary ventilatorinduced lung injury (VILI). The acutely injured lung becomes time and pressure dependent, meaning that it takes more time and pressure to open the lung, and it recollapses more quickly and at higher pressure. Current protective ventilation strategies, ARDSnet low tidal volume (LVt) and the open lung approach (OLA), have been unsuccessful at further reducing ARDS mortality. We postulate that this is because the LVt strategy is constrained to ventilating a lung with a heterogeneous mix of normal and focalized injured tissue, and the OLA, although designed to fully open and stabilize the lung, is often unsuccessful at doing so. In this review we analyzed the pathophysiology of ARDS that renders the lung susceptible to VILI. We also analyzed the alterations in alveolar and alveolar duct mechanics that occur in the acutely injured lung and discussed how these alterations are a key mechanism driving VILI. Our analysis suggests that the time component of each mechanical breath, at both inspiration and expiration, is critical to normalize alveolar mechanics and protect the lung from VILI. Animal studies and a meta-analysis have suggested that the time-controlled adaptive ventilation (TCAV) method, using the airway pressure release ventilation mode, eliminates the constraints of ventilating a lung with heterogeneous injury, since it is highly effective at opening and stabilizing the time-and pressure-dependent lung. In animal studies it has been shown that by "casting open" the acutely injured lung with TCAV we can (1) reestablish normal expiratory lung volume as assessed by direct observation of subpleural alveoli; (2) return normal parenchymal microanatomical structural support, known as alveolar interdependence and parenchymal tethering, as assessed by morphometric analysis of lung histology; (3) facilitate regeneration of normal surfactant function measured as increases in surfactant proteins A and B; and (4) significantly increase lung compliance, which reduces the pathologic impact of driving pressure and mechanical power at any given tidal volume.

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“…Clinical guidelines больных с ОРДС, так и на длительность проведения ИВЛ, продолжительность лечения в ОРИТ и стационаре [102,250,251], при применении маневров рекрутирования альвеол при ОРДС с низкой рекрутабельностью альвеол отмечено увеличение летальности [179]. Улучшение оксигенации у больных с ОРДС вследствие рекрутирования альвеол длится меньше, чем при адекватной настройке РЕЕР [252].…”

Section: клинические рекомендацииunclassified

Diagnostics and intensive therapy of Acute Respiratory Distress Syndrome (Clinical guidelines of the Federation of Anesthesiologists and Reanimatologists of Russia)

Ярошецкий¹,

Грицан²,

Авдеев³

et al. 2020

Anesteziologiya I Reanimatologiya

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РЕЗЮМЕ Рекомендации Общероссийской общественной организации «Федерация анестезиологов и реаниматологов» посвящены современному состоянию проблемы диагностики и лечения острого респираторного дистресс-синдрома. В рекомендациях использован патофизиологический подход к выбору методов интенсивной терапии и респираторной поддержки. На основании представленного анализа даны рекомендации по диагностике и лечению острого респираторного дистресс-синдрома с указанием уровня доказательности и класса рекомендаций. Ключевые слова: клинические рекомендации, острый респираторный дистресс-синдром, искусственная вентиляция легких, высокопоточная оксигенация, дыхательная недостаточность.

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Maximal Recruitment Open Lung Ventilation in Acute Respiratory Distress Syndrome (PHARLAP). A Phase II, Multicenter Randomized Controlled Clinical Trial

Cited by 96 publications

References 27 publications

Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)

Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)

A Physiologically Informed Strategy to Effectively Open, Stabilize, and Protect the Acutely Injured Lung

Diagnostics and intensive therapy of Acute Respiratory Distress Syndrome (Clinical guidelines of the Federation of Anesthesiologists and Reanimatologists of Russia)

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