Quarterly Medical ReviewMechanical ventilation during acute lung injury: Current recommendations and new concepts
Section snippets
Current recommendations: from aiming at normal oxygenation and ventilation to avoiding ventilator-induced lung injury
Despite a very large body of research directed at increasing our understanding and at improving the management of ALI/ARDS [27], [28], [29], [30], [31], [32], no effective pharmacological therapies have been found, and supportive care with mechanical ventilation remains the cornerstone of treatment [33]. In the past, traditional approaches to mechanical ventilation have used tidal volumes of 10 to 15 mL/kg of body weight [34]. These volumes are larger than those in normal subjects at rest
Limitations of the current recommendations
Despite the recommendation of using pressure- and volume-limited ventilatory strategies, VILI may still persist or progress in some patients, resulting in worse outcome.
Lack of adherence to guidelines may be one of the reasons. In fact, Sakr et al. showed in an European multicenter observational study that, 4 years after the publication of the ARDS Network trial, out of 398 patients with ALI or ARDS only 44% received mechanical ventilation with a tidal volume in the range of 5 and 7 mL/kg of PBW,
New concepts
Although the only clinical trial showing a significant decrease of the mortality rate for patients with ALI or ARDS has been published already more than 10 years ago, a very large body of investigations conducted in the last decade has determined significant achievements on the pathophysiological knowledge of VILI. New perspectives have been defined in terms of the efficiency and efficacy of recognizing, monitoring and treating VILI, which will eventually lead to further significant improvement
Conclusions and implications
Acute respiratory failure, especially in the more severe forms of ALI and ARDS, remains a challenging medical problem in the intensive care setting. In the recent past, there have been made exciting advances, which have been summarized in this review. It is increasingly likely that the integration of physiological, technological and clinical discoveries will continue to improve the outcome of patients with acute respiratory failure in the future.
Disclosure of interest
the authors declare that they have no conflicts of interest concerning this article
Glossary
- AECC
- American–European Consensus Conference
- ALI
- acute lung injury
- ARDS
- acute respiratory distress syndrome
- DAD
- diffuse alveolar damage
- ECMO
- extracorporeal membrane oxygenation
- EIT
- electrical impedance tomography
- FRC
- functional residual capacity
- HFO
- high frequency oscillatory
- HFP
- high frequency percussive
- MOF
- multi-organ failure
- NAVA
- neurally adjusted ventilatory assist
- NIV
- noninvasive mechanical ventilation
- NMBA
- neuromuscular blocking agents
- PEEP
- positive end-expiratory pressure
- RM
- recruitment maneuver
- VILI
References (142)
- et al.
Epidemiology and outcomes of acute lung injury
Chest
(2007) - et al.
Acute respiratory distress in adults
Lancet
(1967) - et al.
The role of open-lung biopsy in ARDS
Chest
(2004) - et al.
Time to change diagnostic criteria of ARDS: towards the disease entity-based subgrouping
Pulm Pharmacol Ther
(2005) - et al.
Is the mortality higher in the pulmonary vs the extrapulmonary ARDS? A meta analysis
Chest
(2008) - et al.
Causes and timing of death in patients with ARDS
Chest
(2005) - et al.
Why do patients who have acute lung injury/acute respiratory distress syndrome die from multiple organ dysfunction syndrome? Implications for management
Clin Chest Med
(2006) Evolving concepts in the ventilatory management of acute respiratory distress syndrome
Clin Chest Med
(1996)- et al.
High tidal volume and positive fluid balance are associated with worse outcome in acute lung injury
Chest
(2005) - et al.
Severe hypoxemic respiratory failure: part 1–ventilatory strategies
Chest
(2010)
Regional ventilation by electrical impedance tomography: a comparison with ventilation scintigraphy in pigs
Chest
Efficacy of prone ventilation in adult patients with acute respiratory failure: a meta-analysis
J Crit Care
Prone positioning in hypoxemic respiratory failure: meta-analysis of randomized controlled trials
J Crit Care
Incidence and outcomes of acute lung injury
N Engl J Med
The acute respiratory distress syndrome
N Engl J Med
Efficacy of low tidal volume ventilation in patients with different clinical risk factors for acute lung injury and the acute respiratory distress syndrome
Am J Respir Crit Care Med
The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination
Am J Respir Crit Care Med
Identifying patients with ARDS: time for a different approach
Intensive Care Med
The search for “objective” criteria of ARDS
Intensive Care Med
Current definitions of acute lung injury and the acute respiratory distress syndrome do not reflect their true severity and outcome
Intensive Care Med
Comparison of clinical criteria for the acute respiratory distress syndrome with autopsy findings
Ann Intern Med
Acute respiratory distress syndrome caused by pulmonary and extrapulmonary disease. Different syndromes?
Am J Respir Crit Care Med
Tidal volume reduction for prevention of ventilator-induced lung injury in acute respiratory distress syndrome. The Multicenter Trail Group on Tidal Volume reduction in ARDS
Am J Respir Crit Care Med
Alveolar recruitment in pulmonary and extrapulmonary acute respiratory distress syndrome: comparison using pressure-volume curve or static compliance
Anesthesiology
Clinical risks for development of the acute respiratory distress syndrome
Am J Respir Crit Care Med
Improved survival of patients with acute respiratory distress syndrome (ARDS): 1983–1993
JAMA
Identification of patients with acute lung injury. Predictors of mortality
Am J Respir Crit Care Med
Acute lung injury in the medical ICU: comorbid conditions, age, etiology, and hospital outcome
Am J Respir Crit Care Med
An early PEEP/FiO2 trial identifies different degrees of lung injury in patients with acute respiratory distress syndrome
Am J Respir Crit Care Med
Airway pressures, tidal volumes, and mortality in patients with acute respiratory distress syndrome
Crit Care Med
Outcome after acute respiratory failure is more dependent on dysfunction in other vital organs than on the severity of the respiratory failure
Crit Care
Has mortality from acute respiratory distress syndrome decreased over time? A systematic review
Am J Respir Crit Care Med
Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome
N Engl J Med
Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome
N Engl J Med
Recruitment maneuvers for acute lung injury: a systematic review
Am J Respir Crit Care Med
Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial
JAMA
Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial
JAMA
Effect of adrenoreceptors on endotoxin-induced cytokines and lipid peroxidation in lung explants
Am J Respir Crit Care Med
Ventilatory management of acute lung injury and acute respiratory distress syndrome
JAMA
Ventilator-associated lung injury: a search for better therapeutic targets
Eur Respir J
Ventilator-induced lung injury: from the bench to the bedside
Intensive Care Med
Overview of ventilator-induced lung injury mechanisms
Curr Opin Crit Care
Perspective on lung injury and recruitment: a skeptical look at the opening and collapse story
Am J Respir Crit Care Med
Ventilator-induced injury: from barotrauma to biotrauma
Proc Assoc Am Physicians
Ventilator-induced lung injury and multiple system organ failure: a critical review of facts and hypotheses
Intensive care medicine
Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation
Crit Care Med
Ventilator settings as a risk factor for acute respiratory distress syndrome in mechanically ventilated patients
Intensive Care Med
High tidal volume is associated with the development of acute lung injury after severe brain injury: an international observational study
Crit Care Med
Acute lung injury in patients with severe brain injury: a double hit model
Neurocrit Care
Consensus conference on mechanical ventilation–January 28–30, 1993 at Northbrook, Illinois, USA. Part I. European Society of Intensive Care Medicine, the ACCP and the SCCM
Intensive Care Med
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