The Impact of Spontaneous Ventilation on Distribution of Lung Aeration in Patients with Acute Respiratory Distress Syndrome: Airway Pressure Release Ventilation Versus Pressure Support Ventilation

Yoshida, Toyohiko; Rinka, Hiroshi; Kaji, Arito; Yoshimoto, Akira; Arimoto, Hideki; Miyaichi, Toshinori; Kan, Masanori

doi:10.1213/ane.0b013e3181bbd918

Cited by 94 publications

(62 citation statements)

References 33 publications

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“…In contrast, although PS improved both the PaO 2 and shunt, the results were not as good as those observed under APRV + SV [113]. Because the active contraction of the diaphragm is better preserved under APRV+SV than under PS in patients with severe ARDS, active contraction of the diaphragm throughout inspiration is presumably very important: APRV+SV increases the aeration of atelectatic areas more powerfully than PS [114]. The lung tissue recruited by the active contraction of the diaphragm stays open with spontaneous breathing, whereas slow derecruitment occurs with mechanical breathing [36].…”

Section: ) or < 26 CM H 2 O [41] When The Rv Is Considered ( § I A 2)mentioning

confidence: 85%

Early severe acute respiratory distress syndrome: What’s going on? Part I: pathophysiology

Petitjeans

Pichot²,

Ghignone

et al. 2016

Anaesthesiol Intensive Ther

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Severe acute respiratory distress syndrome (ARDS, PaO 2 /FiO 2 < 100 on PEEP ≥ 5 cm H 2 O) is treated using controlled mechanical ventilation (CMV), recently combined with muscle relaxation for 48 h and prone positioning. While the amplitude of tidal volume appears set £ 6 mL kg -1 , the level of positive end-expiratory pressure (PEEP) remains controversial. This overview summarizes several salient points, namely: a) ARDS is an oxygenation defect: consolidation/difuse alveolar damage is reversed by PEEP and/or prone positioning, at least during the early phase of ARDS b) ARDS is a dynamic disease and partially iatrogenic. This implies that the management of the ventilator may be a life-saver by reducing the duration of mechanical ventilation, or detrimental by extending this duration, leading into critical care-acquired diseases. Indeed, a high PEEP (10−24 cm H 2 O) appears to be a life-saver in the context of early severe diffuse ARDS; c) tidal volume and plateau pressure cannot be identical for all patients; d) the only remaining rationale for CMV and muscle relaxation is to suppress patient-ventilator asynchrony and to lower VO 2 , during the acute cardio-ventilatory distress. Therefore, in early severe diffuse ARDS, this review argues for a combination of a high PEEP (preferably titrated on transpulmonary pressure) with spontaneous ventilation + pressure support (or newer modes of ventilation). However, conditionalities are stringent: upfront circulatory optimization, upright positioning, lowered VO 2 , lowered acidotic and hypercapnic drives, sedation without ventilatory depression and without lowered muscular tone. As these propositions require evidence-based demonstration, the accepted practice remains, in 2016, controlled mechanical ventilation, muscle relaxation, and prone position.

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Section: ) or < 26 CM H 2 O [41] When The Rv Is Considered ( § I A 2)mentioning

confidence: 85%

Early severe acute respiratory distress syndrome: What’s going on? Part I: pathophysiology

Petitjeans

Pichot²,

Ghignone

et al. 2016

Anaesthesiol Intensive Ther

View full text Add to dashboard Cite

show abstract

“…The expiratory flow curve is analyzed, and the ratio of the end-expiratory flow (EEF) to the peak expiratory flow (PEF) is set so that the EEF/PEF ratio is 75 % [5,[49][50][51][52][53][54][55][56][57][58][59][60][61][62] (See figure on previous page.) Fig.…”

Section: How Expiratory Duration Was Personalizedmentioning

confidence: 99%

“…However, all of the human trials testing the P-APRV method [50,53,[58][59][60] are retrospective studies, and as such, it is not clear that the precise P-APRV settings were followed, aside from the study by Andrews et al [50] that strictly adhered to the P-APRV protocol throughout the study in trauma patients. Despite this, the human results are in concordance with multiple animal studies [5, 49, 54-57, 61, 62] that support the clinical data [50] that P-APRV may be used to reduce the incidence of acute respiratory distress syndrome (ARDS) more effectively than conventional LTV ventilation applied early or after the onset of ARDS.…”

Section: P-aprvmentioning

confidence: 99%

Experiences Using Airway Pressure Release Ventilation for Pneumonia with Severe Hypercapnia or Postoperative Pulmonary Edema

Hong

Lee

2017

Korean J Crit Care Med

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Airway pressure release ventilation (APRV) was first described in 1987 and defined as continuous positive airway pressure (CPAP) with a brief release while allowing the patient to spontaneously breathe throughout the respiratory cycle. The current understanding of the optimal strategy to minimize ventilator-induced lung injury is to "open the lung and keep it open". APRV should be ideal for this strategy with the prolonged CPAP duration recruiting the lung and the minimal release duration preventing lung collapse. However, APRV is inconsistently defined with significant variation in the settings used in experimental studies and in clinical practice. The goal of this review was to analyze the published literature and determine APRV efficacy as a lung-protective strategy. We reviewed all original articles in which the authors stated that APRV was used. The primary analysis was to correlate APRV settings with physiologic and clinical outcomes. Results showed that there was tremendous variation in settings that were all defined as APRV, particularly CPAP and release phase duration and the parameters used to guide these settings. Thus, it was impossible to assess efficacy of a single strategy since almost none of the APRV settings were identical. Therefore, we divided all APRV studies divided into two basic categories: (1) fixed-setting APRV (F-APRV) in which the release phase is set and left constant; and (2) personalized-APRV (P-APRV) in which the release phase is set based on changes in lung mechanics using the slope of the expiratory flow curve. Results showed that in no study was there a statistically significant worse outcome with APRV, regardless of the settings (F-ARPV or P-APRV). Multiple studies demonstrated that P-APRV stabilizes alveoli and reduces the incidence of acute respiratory distress syndrome (ARDS) in clinically relevant animal models and in trauma patients. In conclusion, over the 30 years since the mode's inception there have been no strict criteria in defining a mechanical breath as being APRV. P-APRV has shown great promise as a highly lung-protective ventilation strategy.

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“…A higher MAP was observed under APRV+SV than under PS and was presumably linked to an active compression of blood from the viscerae by the diaphragm [25]. The reader should note that, presumably, very low P/F values [40−66] were handled with spontaneous ventilation [26].…”

Section: Analysis Of the Blood Gasesmentioning

confidence: 99%

Early severe acute respiratory distress syndrome: What’s going on? Part II: controlled vs. spontaneous ventilation?

Petitjeans

Pichot

Ghignone

et al. 2016

Anaesthesiol Intensive Ther

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The second part of this overview on early severe ARDS delineates the pros and cons of the following: a) controlled mechanical ventilation (CMV: lowered oxygen consumption and perfect patient-to-ventilator synchrony), to be used during acute cardio-ventilatory distress in order to "buy time" and correct circulatory insufficiency and metabolic defects (acidosis, etc.); b) spontaneous ventilation (SV: improved venous return, lowered intrathoracic pressure, absence of muscle atrophy). Given a stabilized early severe ARDS, as soon as the overall clinical situation improves, spontaneous ventilation will be used with the following stringent conditionalities: upfront circulatory optimization, upright positioning, lowered VO 2 , lowered acidotic and hypercapnic drives, sedation without ventilatory depression and without lowered muscular tone, as well as high PEEP (titrated on transpulmonary pressure, or as a second best: "trial"-PEEP) with spontaneous ventilation + pressure support (or newer modes of ventilation). As these propositions require evidence-based demonstration, the reader is reminded that the accepted practice remains, in 2016, controlled mechanical ventilation, muscle relaxation and prone position. Anestezjologia Intensywna Terapia 2016, tom 48, nr 5, 354-366Key words: acute respiratory distress syndrome, ARDS, severe ARDS; acute hypoxic non-hypercapnic respiratory failure; driving pressure; tidal volume, Vt, low tidal volume, ultra-low tidal volume; positive end-expiratory pressure, PEEP; transpulmonary pressure; controlled mechanical ventilation; spontaneous ventilation; spontaneous breathing; pressure support, airway pressure release ventilation; sedation, cooperative sedation; alpha-2 adrenergic agonist, clonidine, dexmedetomidineThe previous chapter overviewed, for residents rotating through the critical care unit (CCU), basic pathophysiology required to analyze early severe acute respiratory distress syndrome (ARDS). An emphasis was placed on spontaneous ventilation both in the setting of the healthy volunteer and of severe ARDS. This chapter will address the pros and cons of controlled mechanical ventilation, with the help of muscle relaxation, as opposed to the putative advantages of spontaneous ventilation. So far, spontaneous ventilation has not achieved evidence-based demonstration: thus, as in part I, conjectures are within [….], following [1]. i. MUSCLE RELAXATiON VERSUS SPONTANEOUS VENTiLATiON?When muscle relaxation is considered, the overall picture appears to be simplified with 48 h of muscle relaxation [2]. A sober interpretation may be considered. a. Muscle relaxationIn severe ARDS (P/F < 120), muscle relaxation [2] lowered the mortality (45 to 31%; difference of −32%; P = 0.04), multiple organ failure (MOF), and barotrauma and led to more ventilator-free days and identical CCU-acquired paresis. Muscle relaxation was hypothesized to minimize excessive transpulmonary pressure, patient-to-ventilator asynchrony [2], ventilator-induced lung injury (VILI), atelectrauma, overdistension,...

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The Impact of Spontaneous Ventilation on Distribution of Lung Aeration in Patients with Acute Respiratory Distress Syndrome: Airway Pressure Release Ventilation Versus Pressure Support Ventilation

Cited by 94 publications

References 33 publications

Early severe acute respiratory distress syndrome: What’s going on? Part I: pathophysiology

Early severe acute respiratory distress syndrome: What’s going on? Part I: pathophysiology

Experiences Using Airway Pressure Release Ventilation for Pneumonia with Severe Hypercapnia or Postoperative Pulmonary Edema

Early severe acute respiratory distress syndrome: What’s going on? Part II: controlled vs. spontaneous ventilation?

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