Elsevier

La Presse Médicale

Volume 40, Issue 12, Part 2, December 2011, Pages e569-e583
La Presse Médicale

Quarterly Medical Review
Mechanical ventilation during acute lung injury: Current recommendations and new concepts

https://doi.org/10.1016/j.lpm.2011.05.028Get rights and content

Summary

Despite a very large body of investigations, no effective pharmacological therapies have been found to cure acute lung injury. Hence, supportive care with mechanical ventilation remains the cornerstone of treatment. However, several experimental and clinical studies showed that mechanical ventilation, especially at high tidal volumes and pressures, can cause or aggravate ALI. Therefore, current clinical recommendations are developed with the aim of avoiding ventilator-induced lung injury (VILI) by limiting tidal volume and distending ventilatory pressure according to the results of the ARDS Network trial, which has been to date the only intervention that has showed success in decreasing mortality in patients with ALI/ARDS. In the past decade, a very large body of investigations has determined significant achievements on the pathophysiological knowledge of VILI. Therefore, new perspectives, which will be reviewed in this article, have been defined in terms of the efficiency and efficacy of recognizing, monitoring and treating VILI, which will eventually lead to further significant improvement of outcome in patients with ARDS.

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

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