Adjusting tidal volume to stress index in an open lung condition optimizes ventilation and prevents overdistension in an experimental model of lung injury and reduced chest wall compliance

Ferrando, Carlos; Suárez-Sipmann, Fernando; Gutiérrez, Andrea; Tusman, Gerardo; Carbonell, J; García, M. Ruiz; Piqueras, Laura; Compañ, Desamparados; Flores, Susanie; Soro, Marina; Llombart, Alicia; Belda, F. Javier

doi:10.1186/s13054-014-0726-3

Cited by 23 publications

(13 citation statements)

References 46 publications

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“…This will also reduce the driving pressure required [ 9 , 10 ]. It would allow more individualized settings based on physiologic measurements and considerations [ 11 – 13 ].…”

Section: Ventilatory Setting I: Tidal Volume/respiratory Ratementioning

confidence: 99%

The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia

et al. 2016

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Purpose: Severe ARDS is often associated with refractory hypoxemia, and early identification and treatment of hypoxemia is mandatory. For the management of severe ARDS ventilator settings, positioning therapy, infection control, and supportive measures are essential to improve survival. Methods and results:A precise definition of life-threating hypoxemia is not identified. Typical clinical determinations are: arterial partial pressure of oxygen < 60 mmHg and/or arterial oxygenation < 88 % and/or the ratio of PaO 2 /FIO 2 < 100. For mechanical ventilation specific settings are recommended: limitation of tidal volume (6 ml/ kg predicted body weight), adequate high PEEP (>12 cmH 2 O), a recruitment manoeuvre in special situations, and a 'balanced' respiratory rate (20-30/min). Individual bedside methods to guide PEEP/recruitment (e.g., transpulmonary pressure) are not (yet) available. Prone positioning [early (≤ 48 hrs after onset of severe ARDS) and prolonged (repetition of 16-hr-sessions)] improves survival. An advanced infection management/control includes early diagnosis of bacterial, atypical, viral and fungal specimen (blood culture, bronchoalveolar lavage), and of infection sources by CT scan, followed by administration of broad-spectrum anti-infectives. Neuromuscular blockage (Cisatracurium ≤ 48 hrs after onset of ARDS), as well as an adequate sedation strategy (score guided) is an important supportive therapy. A negative fluid balance is associated with improved lung function and the use of hemofiltration might be indicated for specific indications. Conclusions:A specific standard of care is required for the management of severe ARDS with refractory hypoxemia.

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“…This will also reduce the driving pressure required [ 9 , 10 ]. It would allow more individualized settings based on physiologic measurements and considerations [ 11 – 13 ].…”

Section: Ventilatory Setting I: Tidal Volume/respiratory Ratementioning

confidence: 99%

The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia

et al. 2016

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“…Since both alveolar opening and collapse time constants vary depending on lung injury severity and evolve as the lung pathology improves or deteriorates, ventilator settings must be constantly adjusted to fit the specific needs of the individual [ 12 – 19 ]. The components that comprise the Mechanical Breath Profile (MB P ) (i.e., airway pressures, flows, volumes, rates, and the duration that they are applied during each breath) have been targeted for personalization [ 20 – 22 ], but personalized PEEP has been the most studied. Multiple studies have reviewed or tested methods to apply PEEP using the pathology of the lung [ 23 – 30 ].…”

Section: Reviewmentioning

confidence: 99%

Personalizing mechanical ventilation according to physiologic parameters to stabilize alveoli and minimize ventilator induced lung injury (VILI)

Nieman

Satalin

Andrews

et al. 2017

ICMx

113

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It has been shown that mechanical ventilation in patients with, or at high-risk for, the development of acute respiratory distress syndrome (ARDS) can be a double-edged sword. If the mechanical breath is improperly set, it can amplify the lung injury associated with ARDS, causing a secondary ventilator-induced lung injury (VILI). Conversely, the mechanical breath can be adjusted to minimize VILI, which can reduce ARDS mortality. The current standard of care ventilation strategy to minimize VILI attempts to reduce alveolar over-distension and recruitment-derecruitment (R/D) by lowering tidal volume (Vt) to 6 cc/kg combined with adjusting positive-end expiratory pressure (PEEP) based on a sliding scale directed by changes in oxygenation. Thus, Vt is often but not always set as a “one-size-fits-all” approach and although PEEP is often set arbitrarily at 5 cmH2O, it may be personalized according to changes in a physiologic parameter, most often to oxygenation. However, there is evidence that oxygenation as a method to optimize PEEP is not congruent with the PEEP levels necessary to maintain an open and stable lung. Thus, optimal PEEP might not be personalized to the lung pathology of an individual patient using oxygenation as the physiologic feedback system. Multiple methods of personalizing PEEP have been tested and include dead space, lung compliance, lung stress and strain, ventilation patterns using computed tomography (CT) or electrical impedance tomography (EIT), inflection points on the pressure/volume curve (P/V), and the slope of the expiratory flow curve using airway pressure release ventilation (APRV). Although many studies have shown that personalizing PEEP is possible, there is no consensus as to the optimal technique. This review will assess various methods used to personalize PEEP, directed by physiologic parameters, necessary to adaptively adjust ventilator settings with progressive changes in lung pathophysiology.

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“…37 In a recent animal model of ARDS with decreased C CW from abdominal restriction, a safe stress index (ie, approximately 1 in each group) could be achieved at the same PEEP level and higher V T (7.3 Ϯ 0.7 mL/kg vs 5.4 Ϯ 0.8 mL/kg) and higher P plat (35 Ϯ 2 cm H 2 O vs 30 Ϯ 1 cm H 2 O) with similar degrees of oxygenation and substantially less hypercarbia. 38…”

Section: Application Of Peep Guided By Stress Indexmentioning

confidence: 99%

Should PEEP Titration Be Based on Chest Mechanics in Patients With ARDS?

Kallet

2016

Respir Care

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Functional residual capacity (FRC) is essentially the alveolar volume and a determinant of both oxygenation and respiratory system compliance (CRS). ARDS decreases FRC, and sufficient PEEP restores FRC; thus, assessments of PEEP by its impact on oxygenation and CRS are intimately linked. PEEP also can ameliorate or aggravate ventilator-induced lung injury. Therefore, it can be argued that PEEP should be titrated primarily by its impact on CRS The pro position argues that the heterogeneous nature of lung injury and its unique presentation in individual patients results in an uncoupling between oxygenation and CRS Therefore, relying upon oxygenation alone may enhance lung injury and mortality risk, particularly in those with severe ARDS. The con argument is that the preponderance of preclinical and clinical evidence suggests that a relatively narrow range of PEEP is required to manage all but the most severe cases of ARDS. In addition, pathological alterations in chest wall compliance confuse the interpretation of chest mechanics. Moreover, ambiguities and technical limitations in advanced techniques, such as esophageal manometry and pressure-volume curves, add a layer of complexity that renders its broader application in all ARDS patients both impractical and unnecessary. Whether sophisticated monitoring of chest mechanics in severe ARDS might improve outcomes further is open to question and should be studied further. However, it is highly improbable that we will ever discover a PEEP strategy that optimizes all aspects of cardiorespiratory function and chest mechanics for individual patients suffering from ARDS.

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Adjusting tidal volume to stress index in an open lung condition optimizes ventilation and prevents overdistension in an experimental model of lung injury and reduced chest wall compliance

Cited by 23 publications

References 46 publications

The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia

The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia

Personalizing mechanical ventilation according to physiologic parameters to stabilize alveoli and minimize ventilator induced lung injury (VILI)

Should PEEP Titration Be Based on Chest Mechanics in Patients With ARDS?

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