Rationale and Description of Right Ventricle-Protective Ventilation in ARDS

Abstract

Pulmonary vascular dysfunction is associated with ARDS and leads to increased right-ventricular afterload and eventually right-ventricular failure, also called acute cor pulmonale. Interest in acute cor pulmonale and its negative impact on outcome in patients with ARDS has grown in recent years. Right-ventricular function in these patients should be closely monitored, and this is helped by the widespread use of echocardiography in intensive care units. Because mechanical ventilation may worsen right-ventricular failure, the interaction between the lungs and the right ventricle appears to be a key factor in the ventilation strategy. In this review, a rationale for a right ventricle-protective ventilation approach is provided, and such a strategy is described, including the reduction of lung stress (ie, the limitation of plateau pressure and driving pressure), the reduction of PaCO2 , and the improvement of oxygenation. Prone positioning seems to be a crucial part of this strategy by protecting both the lungs and the right ventricle, resulting in increased survival of patients with ARDS. Further studies are required to validate the positive impact on prognosis of right ventricle-protective mechanical ventilation.

Performance of a capnodynamic method estimating cardiac output during respiratory failure - before and after lung recruitment

“…Lung protective mechanical ventilation commonly improves compliance and oxygenation. However, the accompanying high levels of PEEP can increase the right ventricular afterload with negative effect on the cardiac performance [2,3]. Hemodynamic monitoring is therefore of great importance to optimize blood perfusion to the injured lungs with least possible strain on the right ventricle.…”

Clinical presentation and management of right ventricular dysfunction

“…It is increasingly being recognised that modern ventilatory practices with low tidal volumes and high PEEP have the potential to adversely affect RV function, with some experts recommending an 'RV protective approach' to mechanical ventilation in ARDS, such that protective strategy focuses on limiting plateau pressure to reduce lung stress, improving oxygenation to limit the effect of hypoxic vasoconstriction and preventing hypercapnia. 15 Tidal volume and PEEP should aim to maintain a plateau pressure <27cmH 2 0, a driving pressure <18cmH 2 0 and ideally a PaC0 2 <48mmHg. 15 If the respiratory rate is adjusted, this should be done carefully as this may induce intrinsic PEEP and dynamic hyperinflation worsening RV dysfunction.…”

“…15 Tidal volume and PEEP should aim to maintain a plateau pressure <27cmH 2 0, a driving pressure <18cmH 2 0 and ideally a PaC0 2 <48mmHg. 15 If the respiratory rate is adjusted, this should be done carefully as this may induce intrinsic PEEP and dynamic hyperinflation worsening RV dysfunction. Ventilation in the prone position has been shown to induce alveolar recruitment and reduce RV afterload.…”

Effects of Quality Control Targets (SpO2≠100%, PaCO2/<40 mmHg, Pmean/>10 cmH2O) on Outcomes in Patients in the ICU

“…The need for a small tidal volume in lung protective ventilation has been recognized (4,5). The impact of mechanical ventilation on the circulation has increasingly become a point of concern and a research hot spot (6)(7)(8). In our daily work, three parameters are used to control the effects of mechanical ventilation on breathing and circulation in critically ill patients: SpO2, PaCO2, and Pmean.…”