Ventilation Strategy Using Low Tidal Volumes, Recruitment Maneuvers, and High Positive End-Expiratory Pressure for Acute Lung Injury and Acute Respiratory Distress Syndrome

Abstract

CUTE LUNG INJURY AND ACUTE respiratory distress syndrome (ARDS, the most severe form of acute lung injury), are potentially devastating complications of critical illness. 1 Arising in response to direct lung injury (eg, pneumonia) or intense systemic inflammation (eg, sepsis), 2 the pathogenesis involves pulmonary edema, diffuse cellular destruction, alveolar collapse, and disordered repair. Mortality and health care costs are high, 3 and long-term survivors experience serious morbidity. 4 See also pp 646, 691, and 693.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG2016)

“…For the analysis of in‐hospital mortality, studies permitting interventions other than adjustment of PEEP values capable of influencing patient outcomes were excluded from analysis. As a result, three studies, by Brower et al .,208 Meade et al .,209 and Mercat et al 210. were included in the final analysis.…”

Indications for extracorporeal support: why do we need the results of the EOLIA trial?

“…The most severe forms of the disease, of which hypoxemia resulting from pulmonary involvement is the most profound, have an even worse prognosis, with mortality exceeding 60% [2,3], despite recourse to exceptional adjunctive therapies, such as inhaled NO [4], recruitment maneuvers [5], or prone positioning [6].…”

Rescue therapy for refractory ARDS should be offered early: no

“…As the patient in this case is a woman, it should be mentioned that clinicians tend to use actual body weight instead of PBW for assigning VT and therefore over-ventilate women and people who are of shorter stature [3]. PEEP should be set initially according to the protocol used (standard or high PEEP strategy) [4,5] and is almost certainly too low in this case. Titration of PEEP may benefit the patient.…”

“…A more common way of setting PEEP is to use a PEEP/FIO 2 table. Suppose FIO 2 is 0.80 in this case, PaO 2 would be 52 mmHg and hence PEEP should range from 14 to 22 cmH 2 O depending on the PEEP/FIO 2 table [4,5]. Even though the current concept for setting PEEP is the prevention of the cyclical opening and closing of alveoli during tidal breaths, in a patient like this, the oxygenation response to PEEP is relevant.…”