Acute Hemodynamic Changes of Pressure-controlled Inverse Ratio Ventilation in the Adult Respiratory Distress Syndrome

Poelaert, Jan; Visser, Cees A.; Everaert, Jan A.; Koolen, Jacques; Colardyn, Francis

doi:10.1378/chest.104.1.214

Cited by 34 publications

(22 citation statements)

References 33 publications

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“…In an experimental study [52], comparing five different ventilatory modes in pigs with surfactant depletion, ventilatory volumes and peak airway pressures were lowest in the PC-IRV mode; however, higher mean airway pressures impaired pulmonary circulation and oxygen transport. On the other hand, in a study in 12 ARDS patients haemodynamics improved under PC-IRV, as demonstrated by transoesophageal echocardiography [53]. This demonstrates that haemodynamics and oxygen transport function must always be taken into account and should be an essential criterion when assessing the net advantage of a certain mode of mechanical ventilation.…”

Section: Variation Of the Inspiration:expiration (I:e) Ratiomentioning

confidence: 96%

New strategies in mechanical ventilation for acute lung injury

Burchardi¹

1996

Eur Respir J

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In the fluid-filled lungs of early adult respiratory distress syndrome (ARDS) the dependent parts are compressed and atelectatic; whereas, the nondependent areas remain aerated and functional. Ventilating these considerably restricted lungs carries the risk of overinflation and ventilatory-induced lung injury (baro-volutrauma).The consequences for adjusting mechanical ventilation are: 1) reducing tidal volumes in order to avoid alveolar hyperinflation and excessive alveolar pressures; 2) considering permissive hypercapnia if adequate CO 2 elimination cannot be maintained; 3) keeping open the unstable alveoli by positive end-expiratory pressure (PEEP) (external or intrinsic). However, the large variations in regional lung compliance make it improbable that an optimal external PEEP level beneficial for the whole lung will be found; 4) using intrinsic PEEP in the inverse ratio ventilation (IRV) mode which varies with differences in regional ventilatory kinetics. No clinical study has yet convincingly demonstrated the benefit of IRV compared to conventional ventilation, controlled clinical long-term trials are not yet available; and 5) using superimposed spontaneous breathing which may be considerably more effective in opening up collapsed alveoli, combined with intentional intrinsic PEEP this is achieved in airway pressure release ventilation (APRV).Other new principles of mechanical ventilation, such as "proportional assist ventilation" or "tracheal gas insufflation" must still be considered as experimental. Eur Respir J., 1996Respir J., , 9, 1063 SERIES 'CLINICAL PHYSIOLOGY IN RESPIRATORY INTENSIVE CARE' Edited by A. Rossi and C. RoussosMechanical ventilation and ventilatory support techniques have undergone an impressive evolution within the last 10 yrs. This was due to considerable technical development rather than a radical change in our pathophysiological knowledge. Today, a variety of new techniques are available which facilitate new ventilatory strategies. In this review, only strategies for nonobstructive acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) will be presented and discussed. Strategies for chronic obstructive airways diseases (COPD) differ considerably; they will not be mentioned in this connection. Pathophysiological basisIn ALI and ARDS, (the American-European Consensus Conference on ARDS [1] changed the former expression "adult respiratory distress syndrome" into "acute respiratory distress syndrome", since ARDS is not limited to adults), the hallmark is a critical increase of pulmonary membrane permeability. This can happen by two different pathways: directly by lesion of lung cells; and indirectly as the result of an acute systemic inflammatory reaction (cellular and humoral effects). This results in a bilateral pulmonary interstitial and intra-alveolar (noncardiogenic) oedema.As a consequence, alveoli are compressed or flooded, and the surface for pulmonary gas exchange is considerably reduced by multiple atelectases. In this way, venous admixture and intr...

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Section: Variation Of the Inspiration:expiration (I:e) Ratiomentioning

confidence: 96%

New strategies in mechanical ventilation for acute lung injury

Burchardi¹

1996

Eur Respir J

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“…Besides regular ventilatory modes as pressure controlled ventilation and SIMV, PC-IRV was introduced. Adequacy of use of this ventilatory mode was observed in previous investigations [6,23] despite questions regarding its impact in patient's hemodynamics [15]. The hemodynamic evaluation module introduced in DSSARDS together with the experience of the medical team with this mode gave support to its use.…”

Section: Discussionmentioning

confidence: 83%

“…In addition, studies on the pathophysiology of patients under mechanical ventilation have progressively demonstrated the fundamental role of hemodynamic evaluation for correct adjustment of ventilator settings during ARDS [14,15], a factor not introduced in most previous studies.…”

Section: Introductionmentioning

confidence: 99%

Decision support system to assist mechanical ventilation in the adult respiratory distress syndrome

Bottino

Giannella-Neto

David

et al. 1997

Int. J. Clin. Mon. Comp.

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This paper presents a knowledge-based decision support system to assist mechanical ventilation in patients with the Adult Respiratory Distress Syndrome (DSSARDS). The knowledge base uses clinical algorithms developed from interviews and seminars with experts. The system contains 140 rules, applies backward chaining and was built on an IBM-PC compatible microcomputer. Clinical and physiological data and ventilator settings were used for suggestions of ventilatory support mode (VSMODE) and settings (MVSET) and for hemodynamic evaluation and therapy (HEMO). Success rates (s) and kappa coefficient (k) were used to measure agreement between DSSARDS and physicians at 4 decision steps related to: beginning of mechanical ventilation (FIRSTSET), VSMODE, MVSET and HEMO, DSSARDS prototype was evaluated in a development phase with 6 patients aged 48.6 +/- 15.9 years. Agreement results for 142 decision steps were: FIRSTSET k = 0.90, s = 0.93; VSMODE k = 0.76, s = 0.92; HEMO k = 0.58, s = 0.70, MVSET k = 0.86, s = 0.92 (p < 0.05 for all k). Improvements in the knowledge base were performed mainly in HEMO and VSMODE modules. The subsequent test phase studied 5 patients aged 54.8 +/- 11.0 years in a total of 900 decision steps. Results were: FIRSTSET k = 0.93, s = 0.95; VSMODE k = 0.93, s = 0.96; HEMO k = 0.97, s = 0.99, MVSET k = 0.96, s = 0.97 (p < 0.05 for all k). The results indicate significant agreement between DSSARDS and physicians for all decision steps. This suggests that DSSARDS may be used as a support for decision making and a training tool for mechanical ventilation in patients with the adult respiratory distress syndrome.

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“…Различными авторами в разное время было показано, что положительное давление в легких и лёгочное растяжение, обусловленное ИВЛ с ПДКВ, отрицательно сказываются на различных компонентах кардиогемодинамики (венозный возврат, ДЛА, пред и постнагрузка правого и ле вого желудочков сердца, коронарный кровоток, взаимодействие правого и левого желудочков сердца и др. ), особенно у больных с тяжёлым ОРДС в условиях ИВЛ, когда внутриальвеоляр ное давление намного выше внутриплеврального давления [21][22][23].…”

Section: результаты и обсуждениеunclassified