Prophylactic protective ventilation: lower tidal volumes for all critically ill patients?

Abstract

High tidal volumes have historically been recommended for mechanically ventilated patients during general anesthesia. High tidal volumes have been shown to increase morbidity and mortality in patients suffering from acute respiratory distress syndrome (ARDS). Barriers exist in implementing a tidal volume reduction strategy related to the inherent difficulty in changing one's practice patterns, to the current need to individualize low tidal volume settings only for a specific subgroup of mechanically ventilated patients (i.e., ARDS patients), the difficulty in determining the predicated body weight (requiring the patient's height and a complex formula). Consequently, a protective ventilation strategy is often under-utilized as a therapeutic option, even in ARDS. Recent data supports the generalization of this strategy prophylactically to almost all mechanically ventilated patients beginning immediately following intubation. Using tools to rapidly and reliably determine the predicted body weight (PBW), as well as the use of automated modes of ventilation are some of the potential solutions to facilitate the practice of protective ventilation and to finally ventilate our patients' lungs in a more gentle fashion to help prevent ARDS.

Year in review in Intensive Care Medicine 2013: II. Sedation, invasive and noninvasive ventilation, airways, ARDS, ECMO, family satisfaction, end-of-life care, organ donation, informed consent, safety, hematological issues in critically ill patients

“…Lellouche and Lipes reported the most recent data which supports the generalization of prophylactic protective ventilation which combines at least lower VT (4-8 ml/kg of predicted body weight) and PEEP in almost all mechanically ventilated patients (both with healthy and unhealthy lungs) [16].…”

Categorization in Mechanically Ventilated Pediatric Subjects: A Proposed Method to Improve Quality

“…6,12,[15][16][17][18][19][20][21][22] Inputs such as clinical practice guidelines, standards of care, and policies provide the intent and goals of mechanical ventilation. When clinical knowledge is paired with the clinically relevant continuously available data, it is sent to the algorithms segment to be explored.…”

Manejo del potencial donante cadáver

“…La estrategia protectora duplicó el número de pacientes en que se procuró efectivamente los pulmones (54% vs 27%, p = 0,004). Este estudio recalca la importancia de la ventilación protectora, que debiera ser aplicada en todos los pacientes neurocríticos, incluso aquellos con mal pronós-tico vital 54 .…”