Spontaneous Breathing During Ventilatory Support  Improves Ventilation–Perfusion Distributions in  Patients with Acute Respiratory Distress Syndrome

Putensen, Christian; Mutz, N.; Putensen-Himmer, Gabriele; Zinserling, Jörg

doi:10.1164/ajrccm.159.4.9806077

Cited by 392 publications

(282 citation statements)

References 35 publications

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“…Maintaining spontaneous breathing is beneficial when using APRV, particularly when compared to other ''rescue'' modes such as high frequency ventilation, and in fact it can be challenging to apply APRV in patients who have no respiratory effort. Spontaneous breathing with APRV improves alveolar ventilation and has been shown to improve V/Q matching in both adult 14 and animal studies. 15 It improves renal blood flow 16 and intestinal perfusion.…”

Section: Discussionmentioning

confidence: 99%

Airway pressure release ventilation: A pediatric case series

Krishnan¹,

Morrison²

2006

Pediatric Pulmonology

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Summary. Airway pressure release ventilation (APRV) is a relatively new mode of mechanical ventilation (MV) first described in animal studies in 1987 and in humans in 1988. It is a timetriggered, time-cycled, pressure-limited mode where a high level of continuous positive airway pressure (CPAP) is maintained with brief regular releases in pressure, and spontaneous breathing is allowed throughout the cycle. In theory, it is consistent with a lung protective approach while having some hypothetical advantages over HFOV. The use of this mode of ventilation in pediatrics has been limited. The authors describe their experience with this mode of ventilation in a series of pediatric patients.

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Section: Discussionmentioning

confidence: 99%

Airway pressure release ventilation: A pediatric case series

Krishnan¹,

Morrison²

2006

Pediatric Pulmonology

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“…To our surprise, high PEEP combined to "Smart Care" software (Evita 4 XL/Infinity V500, Drager) allows one to achieve early and easy weaning in the setting of severe acute hypoxemic failure in a morbidly obese patient [30] b) FiO 2 ( This result could be due to an active diaphragmatic contraction, throughout inspiration, the recruitment of previously unventilated alveoli, or to a redistribution of the flow towards previously ventilated lung units. Additionally, PS appears to be superior to CMV but inferior to APRV+SV [22,23]. Accordingly, when P/F < 300, APRV appears to be superior compared to PS.…”

Section: Analysis Of the Blood Gasesmentioning

confidence: 90%

Early severe acute respiratory distress syndrome: What’s going on? Part II: controlled vs. spontaneous ventilation?

Petitjeans

Pichot

Ghignone

et al. 2016

Anaesthesiol Intensive Ther

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The second part of this overview on early severe ARDS delineates the pros and cons of the following: a) controlled mechanical ventilation (CMV: lowered oxygen consumption and perfect patient-to-ventilator synchrony), to be used during acute cardio-ventilatory distress in order to "buy time" and correct circulatory insufficiency and metabolic defects (acidosis, etc.); b) spontaneous ventilation (SV: improved venous return, lowered intrathoracic pressure, absence of muscle atrophy). Given a stabilized early severe ARDS, as soon as the overall clinical situation improves, spontaneous ventilation will be used with the following stringent conditionalities: upfront circulatory optimization, upright positioning, lowered VO 2 , lowered acidotic and hypercapnic drives, sedation without ventilatory depression and without lowered muscular tone, as well as high PEEP (titrated on transpulmonary pressure, or as a second best: "trial"-PEEP) with spontaneous ventilation + pressure support (or newer modes of ventilation). As these propositions require evidence-based demonstration, the reader is reminded that the accepted practice remains, in 2016, controlled mechanical ventilation, muscle relaxation and prone position. Anestezjologia Intensywna Terapia 2016, tom 48, nr 5, 354-366Key words: acute respiratory distress syndrome, ARDS, severe ARDS; acute hypoxic non-hypercapnic respiratory failure; driving pressure; tidal volume, Vt, low tidal volume, ultra-low tidal volume; positive end-expiratory pressure, PEEP; transpulmonary pressure; controlled mechanical ventilation; spontaneous ventilation; spontaneous breathing; pressure support, airway pressure release ventilation; sedation, cooperative sedation; alpha-2 adrenergic agonist, clonidine, dexmedetomidineThe previous chapter overviewed, for residents rotating through the critical care unit (CCU), basic pathophysiology required to analyze early severe acute respiratory distress syndrome (ARDS). An emphasis was placed on spontaneous ventilation both in the setting of the healthy volunteer and of severe ARDS. This chapter will address the pros and cons of controlled mechanical ventilation, with the help of muscle relaxation, as opposed to the putative advantages of spontaneous ventilation. So far, spontaneous ventilation has not achieved evidence-based demonstration: thus, as in part I, conjectures are within [….], following [1]. i. MUSCLE RELAXATiON VERSUS SPONTANEOUS VENTiLATiON?When muscle relaxation is considered, the overall picture appears to be simplified with 48 h of muscle relaxation [2]. A sober interpretation may be considered. a. Muscle relaxationIn severe ARDS (P/F < 120), muscle relaxation [2] lowered the mortality (45 to 31%; difference of −32%; P = 0.04), multiple organ failure (MOF), and barotrauma and led to more ventilator-free days and identical CCU-acquired paresis. Muscle relaxation was hypothesized to minimize excessive transpulmonary pressure, patient-to-ventilator asynchrony [2], ventilator-induced lung injury (VILI), atelectrauma, overdistension,...

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“…In humans, APRV + SV improved the VA/Q distribution [113]. In contrast, although PS improved both the PaO 2 and shunt, the results were not as good as those observed under APRV + SV [113]. Because the active contraction of the diaphragm is better preserved under APRV+SV than under PS in patients with severe ARDS, active contraction of the diaphragm throughout inspiration is presumably very important: APRV+SV increases the aeration of atelectatic areas more powerfully than PS [114].…”

Section: ) or < 26 CM H 2 O [41] When The Rv Is Considered ( § I A 2)mentioning

confidence: 92%

“…Diaphragmatic contractions reduce the curvature of the diaphragm, unfold the alveoli, recruit flooded or collapsed areas (better ventilation) and counteract hypoxic vasoconstriction to these newly recruited areas (better perfusion) [112]. In humans, APRV + SV improved the VA/Q distribution [113]. In contrast, although PS improved both the PaO 2 and shunt, the results were not as good as those observed under APRV + SV [113].…”

Section: ) or < 26 CM H 2 O [41] When The Rv Is Considered ( § I A 2)mentioning

confidence: 99%

Early severe acute respiratory distress syndrome: What’s going on? Part I: pathophysiology

Petitjeans

Pichot²,

Ghignone

et al. 2016

Anaesthesiol Intensive Ther

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Severe acute respiratory distress syndrome (ARDS, PaO 2 /FiO 2 < 100 on PEEP ≥ 5 cm H 2 O) is treated using controlled mechanical ventilation (CMV), recently combined with muscle relaxation for 48 h and prone positioning. While the amplitude of tidal volume appears set £ 6 mL kg -1 , the level of positive end-expiratory pressure (PEEP) remains controversial. This overview summarizes several salient points, namely: a) ARDS is an oxygenation defect: consolidation/difuse alveolar damage is reversed by PEEP and/or prone positioning, at least during the early phase of ARDS b) ARDS is a dynamic disease and partially iatrogenic. This implies that the management of the ventilator may be a life-saver by reducing the duration of mechanical ventilation, or detrimental by extending this duration, leading into critical care-acquired diseases. Indeed, a high PEEP (10−24 cm H 2 O) appears to be a life-saver in the context of early severe diffuse ARDS; c) tidal volume and plateau pressure cannot be identical for all patients; d) the only remaining rationale for CMV and muscle relaxation is to suppress patient-ventilator asynchrony and to lower VO 2 , during the acute cardio-ventilatory distress. Therefore, in early severe diffuse ARDS, this review argues for a combination of a high PEEP (preferably titrated on transpulmonary pressure) with spontaneous ventilation + pressure support (or newer modes of ventilation). However, conditionalities are stringent: upfront circulatory optimization, upright positioning, lowered VO 2 , lowered acidotic and hypercapnic drives, sedation without ventilatory depression and without lowered muscular tone. As these propositions require evidence-based demonstration, the accepted practice remains, in 2016, controlled mechanical ventilation, muscle relaxation, and prone position.

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Spontaneous Breathing During Ventilatory Support Improves Ventilation–Perfusion Distributions in Patients with Acute Respiratory Distress Syndrome

Cited by 392 publications

References 35 publications

Airway pressure release ventilation: A pediatric case series

Airway pressure release ventilation: A pediatric case series

Early severe acute respiratory distress syndrome: What’s going on? Part II: controlled vs. spontaneous ventilation?

Early severe acute respiratory distress syndrome: What’s going on? Part I: pathophysiology

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