Pressure Control Inverse Ratio Ventilation as a Method to Reduce Peak Inspiratory Pressure and Provide Adequate Ventilation and Oxygenation

Lain, David C.; DiBenedetto, Robert J.; Morris, Stephen; Nguyen, An Hoang; Saulters, Robert; Causey, Don

doi:10.1378/chest.95.5.1081

Cited by 137 publications

(30 citation statements)

References 11 publications

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“…In the mid-1980s there were reports of improved oxygenation with pressure controlled inverse-ratio ventilation (PCIRV), [61][62][63][64][65] and for some time in the decade thereafter there was enthusiasm for this method. With PCIRV, an inspiratory time greater than the expiratory time is used to increase mean airway pressure and thus improve arterial oxygenation.…”

Section: Prolonged Inspiratory Time and Inverse Inspiratory-expiratormentioning

confidence: 99%

Approaches to Conventional Mechanical Ventilation of the Patient With Acute Respiratory Distress Syndrome

Hess

2011

Respir Care

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To minimize ventilator-induced lung injury, attention should be directed toward avoidance of alveolar over-distention and cyclical opening and closure of alveoli. The most impressive study of mechanical ventilation to date is the Acute Respiratory Distress Syndrome (ARDS) Network study of higher versus lower tidal volume (V T ), which reported a reduction in mortality from 39.8% to 31.0% with 6 mL/kg ideal body weight rather than 12 mL/kg ideal body weight (number-neededto-treat of 12 patients). To achieve optimal lung protection, the lowest plateau pressure and V T possible should be selected. What is most important is limitation of V T and alveolar distending pressure, regardless of the mode set on the ventilator. Accumulating observational evidence suggests that V T should be limited in all mechanically ventilated patients-even those who do not have ALI/ARDS. Evidence does not support the use of pressure controlled inverse-ratio ventilation. Although zero PEEP is probably injurious, an area of considerable controversy is the optimal setting of PEEP. Available evidence does not support the use of higher PEEP, compared to lower PEEP, in unselected patients with acute lung injury (ALI)/ARDS. However, results of a metaanalysis using individual patients from 3 randomized controlled trials suggest that higher PEEP should be used for ARDS, whereas lower PEEP may be more appropriate in patients with ALI. PEEP should be set to maximize alveolar recruitment while avoiding over-distention. Many approaches for setting PEEP have been described, but evidence is lacking that any one approach is superior to any other. In most, if not all, cases of ALI/ARDS, conventional ventilation strategies can be used effectively to provide lung-protective ventilation strategies.

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Section: Prolonged Inspiratory Time and Inverse Inspiratory-expiratormentioning

confidence: 99%

Approaches to Conventional Mechanical Ventilation of the Patient With Acute Respiratory Distress Syndrome

Hess

2011

Respir Care

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“…Application of these modalities resulted in moderate PIPs of less than 35 cmH 2 O and V T s of about 10 ml/kg during the acute phase of the illness. The main reason we preferred pcCMV to volumecontrolled mechanical ventilation (vcCMV) was that peak airway pressures can be precisely controlled, and often a desired V T can be achieved at lower PIP when using pcCMV instead of vcCMV [9,[45][46][47][48][49]. In an RCT in 28 ARDS patients, Amato et al [50] tested pcCMV with "best PEEP" and PHC (V T < 6 ml/kg; PIP < 40 cmH 2 O) against a control regimen (vcCMV, V T = 12 ml/kg, minimum PEEP-levels, no PHC).…”

Section: Advanced Treatment Without Ecmomentioning

confidence: 99%

“…A closer look at several studies using pcCMV-IRV in ARDS patients suggests that the frequent occurrence of barotrauma can be attributed to the use of high airway pressures exceeding 35 cmH 2 O, which promote barotrauma [8,53,60]. The application of a PIP of 33 ± 8 cmH 2 O in the pcCMV mode instead of 48 ± 14 cmH 2 O in the vcCMV mode reduced the incidence of pneumothorax in severe ARF significantly [49]. Despite the fact that we met these limits in our ARDS patients on average, we observed a high barotrauma rate of 72 %.…”

Section: Advanced Treatment Without Ecmomentioning

confidence: 99%

High survival rate in 122 ARDS patients managed according to a clinical algorithm including extracorporeal membrane oxygenation

et al. 1997

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“…IRV has since also been proposed for ARDS lungs [38][39][40][41][42]. The possible advantages in lungs with considerable ventilation/perfusion mismatching are: 1) the prolonged inspiration ensures a more homogeneous ventilation and keeps collapsible alveoli open for a longer period of time; and 2) during the short expiration slower compartments will not exhale completely, they remain distended by PEEPi (regional or "individual" trapped volume) which is, indeed, intended.…”

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

confidence: 99%

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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Pressure Control Inverse Ratio Ventilation as a Method to Reduce Peak Inspiratory Pressure and Provide Adequate Ventilation and Oxygenation

Cited by 137 publications

References 11 publications

Approaches to Conventional Mechanical Ventilation of the Patient With Acute Respiratory Distress Syndrome

Approaches to Conventional Mechanical Ventilation of the Patient With Acute Respiratory Distress Syndrome

High survival rate in 122 ARDS patients managed according to a clinical algorithm including extracorporeal membrane oxygenation

New strategies in mechanical ventilation for acute lung injury

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