Optimal duration of a sustained inflation recruitment maneuver in ARDS patients

Abstract

In early-onset ARDS patients, most of the recruitment occurs during the first 10 s of a sustained inflation RM. However, hemodynamic impairment is significant after the tenth second of RM.

Recruitment Maneuvers and PEEP Titration

“…The optimal duration of a sustained inflation recruitment maneuver in subjects with ARDS was evaluated by Arnal et al, 23 who applied a 40-cm H 2 O sustained inflation for 30 s in 50 subjects within the first 24 h of meeting ARDS criteria. They found that most of the recruitment occurs during the first 10 s of the maneuver, but hemodynamic impairment was significant after 10 s of initiation.…”

Recruitment by sustained inflation: time for a change

“…The first to be introduced-and until quite recently the most widely employed-was the application of 35-40 cmH 2 O airway pressure for 30-40 s. On rare occasion, even higher pressures may be needed to pry open large numbers of the most stubborn lung units, with some authors describing success with pressures that considerably exceed 50 cmH 2 O [6,7]. Because optimal duration of high pressure application varies inversely with pressure amplitude, the effective time of application may not be nearly as long as traditionally used at the bedside, as the data of this study indicate [3].…”

“…The findings reported by Arnal et al [3] are hardly surprising, given the results of laboratory intercomparisons of recruiting maneuver techniques [11]. In these studies, sustaining high pressure was no more effective than using pressure-controlled ventilation (PCV) that achieved the same plateau value but was associated with more profound hypotension.…”

“…This requirement can be met by either sustaining very high and unrelieved inflation pressure for a nonphysiological duration or by repeating tidal cycles that simultaneously achieve a high peak inflation pressure and transiently employ an elevated PEEP during the recruiting process. In the current issue of Intensive Care Medicine, Arnal et al [3] provide clear evidence that, during the recruiting effort, the incremental gain achieved by sustained inflation (SI) wanes progressively as the risk for adverse consequences builds. The reported data support the notion that the optimal duration of sustained inflation is significantly less than now in common use.…”

Respiratory Care Year in Review 2011: Long-Term Oxygen Therapy, Pulmonary Rehabilitation, Airway Management, Acute Lung Injury, Education, and Management

“…The most commonly used recruitment method is application of a constant airway pressure of 35-40 cm H 2 O for 30 -40 s. This recruitment maneuver improves oxygenation, but also has been associated with self-limited and of short duration hemodynamic compromise. 77 A recent report suggests that most of the recruitment occurs within the initial 10 s of the maneuver and that hemodynamic compromise is likely to occur after 10 -15 s. 78 Arnal et al studied 50 patients with early ARDS. A 40 cm H 2 O recruitment maneuver was applied for 30 s. They found that 50% of the recruited volume was attained within 1.6 s, 95% within 6.8 s, and Ͼ 98% with 10 s of applying the pressure.…”