Open Lung Approach for the Acute Respiratory Distress Syndrome

Kacmarek, Robert M.; Villar, Jesús; Sülemanji, Demet; Montiel, Raquel; Ferrando, Carlos; Blanco, Jesús; Koh, Younsuck; Soler, Juan Alfonso; Martínez, Domingo; Hernández, Marianella; Tucci, Mauro R.; Borges, João Batista; Lubillo, Santiago; Santos, Arnoldo; Araujo, J.B.; Amato, Marcelo Britto Passos; Suárez-Sipmann, Fernando

doi:10.1097/ccm.0000000000001383

Cited by 231 publications

(200 citation statements)

References 35 publications

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“…To date, studies of recruitment maneuvers with hard patient-centered outcomes such as survival have largely incorporated recruitment maneuvers as part of a package of interventions for lung protection; benefits of their isolated use are unclear (4,6,(12)(13)(14). While the opening of collapsed pulmonary units by recruitment maneuvers seems intuitively beneficial, it may be accompanied by harmful over-distension of already well-aerated lung, and determining the balance of benefit vs. harm is challenging.…”

Section: A C U T E R E S P I R a T O R Y D I S T R E S S S Y N D R O mentioning

confidence: 99%

Quantification of lung recruitment by respiratory mechanics and CT imaging: what are the clinical implications?

McKown

Ware

2016

Ann. Transl. Med.

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A c u t e r e s p i r a t o r y d i s t r e s s s y n d r o m e ( A R D S ) i scharacterized by increased elastance of the lung and respiratory system (1). Depending on the precipitating factor, pulmonary vs. extrapulmonary, the distribution of pathologic findings and altered respiratory mechanics in the lung is heterogeneous (2). Portions of the lung can be collapsed and/or fluid-filled while others are well-aerated. In order to facilitate gas exchange, recruitment maneuvers are sometimes employed in patients with ARDS (3). These can be performed with a constant high pressure inspiratory hold for 30-40 seconds (4,5) or via stepwise recruitment by increasing the positive end-expiratory pressure (PEEP) (6), typically followed by application of PEEP at a higher level than the previous baseline to maintain aeration of the recruited lung units (7). Recruitment maneuvers have been proposed as useful tools in managing patients with ARDS in order to add previously non-participatory lung units to gas exchange as well as to assess disease severity. The potential effectiveness of recruitment maneuvers in incorporating previously collapsed lung units into gas exchange or in improving the distension of previously poorly aerated pulmonary units differs from patient to patient consequent to the variability in etiology of the lung injury and the heterogeneity of lung parenchyma (8).A recent study by Chiumello and colleagues compared computed tomographic (CT) to respiratory mechanics methodologies for the measurement of the effectiveness of lung recruitment in ARDS (9). For the CT method, CT scans of the lungs at two levels of inflation were used to assess the effectiveness of increased PEEP for recruitment of new lung units to gas exchange (8). For this method, pulmonary voxels are classified into groups based on relative density as measured by CT Hounsfield units (HU). By established convention, regions with HU of >−100 are designated as having no aeration, −100 to −500 poorly aerated, −500 to −900 good aeration, and −900 to −1,000 as over-distended. Comparing the number of voxels in each group in CT scans performed at 5 cmH 2 O PEEP and 15 cmH 2 O PEEP established recruitment as the change in mass of non-ventilated lung between the CT scans.By contrast, respiratory mechanics methods for determining recruitment measure the change in total lung volume of a single breath at different levels of PEEP compared with the anticipated change in volume if compliance were unchanged. One method (termed the EELV-Cst, RS method by Chiumello et al.) measures the static compliance of the respiratory system for one breath at 5 cmH 2 O PEEP and calculates the anticipated lung volume at 15 cmH 2 O PEEP if compliance were stable. The expected increase is compared with measured end-expiratory lung volume by helium dilution at 15 and 5 cmH 2 O PEEP. The lung volume measured at PEEP 15 cmH 2 O in excess of what was predicted from compliance measurement is attributed to recruitment (10). A related method of slow-flow pressure-volume curves generated...

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Section: A C U T E R E S P I R a T O R Y D I S T R E S S S Y N D R O mentioning

confidence: 99%

Quantification of lung recruitment by respiratory mechanics and CT imaging: what are the clinical implications?

McKown

Ware

2016

Ann. Transl. Med.

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“…The "open lung approach" (OLA) aims to achieve high levels of lung aeration in patients with ARDS by first conducting recruitment maneuvers (RMs) to reverse alveolar collapse and then applying the level of PEEP required to keep the alveoli recruited. The OLA strategy provided promising results in preclinical and pilot clinical trials (9)(10)(11)(12).…”

mentioning

confidence: 99%

What does the Acute Respiratory Distress Syndrome trial (ART) teach us?—it is time for precision medicine and precision trials in critical care!

Fumagalli

2018

J. Thorac. Dis.

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“…The plateau pressures in the Kacmarek study (10) were less than 30 cmH 2 O, suggesting that the inspiratory capacity was not exceeded and thus preventing VILI due to stress rupture. Also the PEEP was higher (static strain) and the Vt was lower (dynamic strain) on days 1 and 3, thus stabilizing the lung and minimizing dynamic strain, which was shown to be the major mechanism of VILI (16,17).…”

mentioning

confidence: 99%

“Open the lung and keep it open”: a homogeneously ventilated lung is a ‘healthy lung’

Satalin¹,

Andrews²,

Gatto³

et al. 2016

Ann. Transl. Med.

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Open Lung Approach for the Acute Respiratory Distress Syndrome

Cited by 231 publications

References 35 publications

Quantification of lung recruitment by respiratory mechanics and CT imaging: what are the clinical implications?

Quantification of lung recruitment by respiratory mechanics and CT imaging: what are the clinical implications?

What does the Acute Respiratory Distress Syndrome trial (ART) teach us?—it is time for precision medicine and precision trials in critical care!

“Open the lung and keep it open”: a homogeneously ventilated lung is a ‘healthy lung’

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