Semin Respir Crit Care Med 2006; 27(4): 396-403
DOI: 10.1055/s-2006-948293
Copyright © 2006 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Ventilatory Management of ALI/ARDS

Neil MacIntyre1
  • 1Division of Pulmonary, Allergy, and Critical Care, Duke University Medical Center, Durham, North Carolina
Further Information

Publication History

Publication Date:
14 August 2006 (online)

ABSTRACT

Acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) describe syndromes of diffuse parenchymal lung injury resulting from a variety of inflammatory triggers. The pathophysiological consequences include stiff, low-compliance lungs with impaired gas exchange. Importantly, there is often marked heterogeneity of disease. Positive pressure ventilation must therefore not only focus on recruiting and ventilating diseased units but must also avoid injuring healthy units. To this end, the goals of mechanical ventilatory support of ALI and ARDS have shifted over the last decade to providing smaller (and thus less injurious) tidal volumes and accepting consequently lower arterial values for PaO2 and the development of respiratory acidosis. This has resulted in significant improvements in outcomes. Future developments will need to further refine this lung protective concept.

REFERENCES

  • 1 Bernard G R, Artigas A, Brigham K L et al.. American-European consensus conference on ARDS.  Am J Respir Crit Care Med. 1994;  149 818-824
  • 2 Petty T L, Ashbaugh D G. The adult respiratory distress syndrome: clinical features, factors influencing prognosis, and principles of management.  Chest. 1971;  60 233-239
  • 3 Fulkerson W J, MacIntyre N R. Pathogenesis and treatment of the adult respiratory distress syndrome.  Arch Intern Med. 1996;  156 29-38
  • 4 Gattinoni L, Pesenti A, Torresin A et al.. Adult respiratory distress syndrome profiles by computed tomography.  J Thorac Imaging. 1988;  3 59-64
  • 5 Gattinoni L, Pesenti A, Baglioni S et al.. Inflammatory pulmonary edema and PEEP: correlation between imaging and physiologic studies.  J Thorac Imaging. 1988;  3 59-64
  • 6 Pratt P C. Pathology of the adult respiratory distress syndrome. In: Thurlbeck WM, Abel MR The Lung: Structure, Function and Disease. Baltimore; Williams and Wilkins 1978: 43-57
  • 7 Pratt P, Vollmer R, Shelburne J, Crapo J. Pulmonary morphology in a multihospital collaborative extracorporeal membrane oxygenation project, I: Light microscopy.  Am J Pathol. 1979;  95 191-214
  • 8 Pinsky M R, Guimond J G. The effects of positive end-expiratory pressure on heart-lung interactions.  J Crit Care. 1991;  6 1-15
  • 9 Wagner P D. Ventilation-perfusion relationships.  Annu Rev Physiol. 1980;  42 235-247
  • 10 Boussarsar M, Thierry G, Jaber S et al.. Relationship between ventilatory settings and barotrauma in the acute respiratory distress syndrome.  Intensive Care Med. 2002;  28 406-413
  • 11 Dreyfuss D, Soler P, Bassett G et al.. High inflation pressure pulmonary edema.  Am Rev Respir Dis. 1988;  137 1159-1164
  • 12 Plotz F B, Slutsky A S, van Vught A J, Heijnen C J. Ventilator-induced lung injury and multiple system organ failure: a critical review of facts and hypotheses.  Intensive Care Med. 2004;  30 1865-1872
  • 13 Webb H H, Tierney D F. Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressures: protection by positive end-expiratory pressure.  Am Rev Respir Dis. 1974;  110 556-565
  • 14 Dreyfuss D, Savmon G. Ventilator induced lung injury: lessons from experimental studies.  Am J Respir Crit Care Med. 1998;  157 294-323
  • 15 Tremblay L, Valenza F, Ribiero S P, Li J, Slutsky A S. Injurious ventilatory strategies increase cytokines and C-fos M-RNA expression in an isolated rat lung model.  J Clin Invest. 1997;  99 944-952
  • 16 Chiumello D, Pristine G, Slutsky A S. Mechanical ventilation affects local and systemic cytokines in an animal model of acute respiratory distress syndrome.  Am J Respir Crit Care Med. 1999;  160 109-116
  • 17 Ranieri V M, Suter P M, Totorella C et al.. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome.  JAMA. 1999;  282 54-61
  • 18 Nahum A, Hoyt J, Schmitz L et al.. Effect of mechanical ventilation strategy on dissemination of intertracheally instilled E-coli in dogs.  Crit Care Med. 1997;  25 1733-1743
  • 19 Rich P B, Reickert C A, Sawada S et al.. Effect of rate and inspiratory flow on ventilator induced lung injury.  J Trauma. 2000;  49 903-911
  • 20 NIH ARDS Network . 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. 2000;  342 1301-1308
  • 21 Villar J, Kacmarek R, Peres-Mendez L et al.. A high positive end expiratory pressure low tidal volume strategy improves outcome in persistent ARDS.  Crit Care Med. 2006;  34 1311-1318
  • 22 Amato M B, Barbas C SV, Medievos D M et al.. Effect of a protective ventilation strategy on mortality in ARDS.  N Engl J Med. 1998;  338 347-354
  • 23 Slutsky A S. ACCP consensus conference: mechanical ventilation.  Chest. 1993;  104 1833-1859
  • 24 MacIntyre N R, McConnell R, Cheng K C, Sane A. Pressure limited breaths improve flow dys-synchrony during assisted ventilation.  Crit Care Med. 1997;  25 1671-1677
  • 25 MacIntyre N R, Branson R D. Feedback enhancements on ventilator breaths. In: Tobin M Principles and Practice of Mechanical Ventilation. 2nd ed. New York; McGraw-Hill 2006
  • 26 Gajic O, Frutos-Vivar F, Esteban A et al.. Ventilator settings as a risk factor for acute respiratory distress syndrome in mechanically ventilated patients.  Intensive Care Med. 2005;  31 922-926
  • 27 Brower R G, Hager D N, Krishman J A et al.. Tidal volume reductions in patients with acute lung injury when plateau pressures are not high.  Am J Resp Crit Care Med. 2005;  172 1241-1245
  • 28 Ranieri V M, Brienza N, Santostasi S et al.. Impairment of lung and chest wall mechanics in patients with acute respiratory distress syndrome: role of abdominal distension.  Am J Respir Crit Care Med. 1997;  156 1082-1091
  • 29 Marini J J, Crooke P S. A general mathematical model for respiratory dynamics relevant to the clinical setting.  Am Rev Respir Dis. 1993;  147 14-24
  • 30 Vassilakopoulos T, Petrof B J. Ventilator-induced diaphragmatic dysfunction.  Am J Respir Crit Care Med. 2004;  169 336-341
  • 31 Raps E C, Bird S J, Hansen-Flashen J. Prolonged muscle weakness after neuromuscular blockade in the ICU.  Crit Care Clin. 1994;  10 799-813
  • 32 American Association for Respiratory Care . Positive end expiratory pressure-state of the art after 20 years.  Respir Care. 1988;  33 417-500
  • 33 Crotti S, Mascheroni D, Caironi P et al.. Recruitment and derecruitment during acute respiratory failure: a clinical study.  Am J Respir Crit Care Med. 2001;  164 131-140
  • 34 Lim S C, Adams A B, Simonson D A et al.. Intercomparison of recruitment maneuver efficacy in three models of acute lung injury.  Crit Care Med. 2004;  32 2371-2377
  • 35 Benito S, Lemaire F. Pulmonary pressure-volume relationship in acute respiratory distress syndrome in adults: role of positive and expiratory pressure.  J Crit Care. 1990;  5 27-34
  • 36 Putensen C, Bain M, Hormann C. Selecting ventilator settings according to the variables derived from the quasi static pressure volume relationship in patients with acute lung injury.  Anesth Analg. 1993;  77 436-447
  • 37 Servillo G, Svantesson C, Beydon L et al.. Pressure-volume curves in acute respiratory failure: automated low flow inflation vs occlusion.  Am J Respir Crit Care Med. 1997;  155 1629-1636
  • 38 Suter P M, Fairley H B, Isenberg M D. Optimum end-expiratory pressure in patients with acute pulmonary failure.  N Engl J Med. 1975;  292 284-289
  • 39 Brower R G, Lanken P N, MacIntyre N et al.. National Heart, Lung, and Blood Institute ARDS Clinical Trials Network. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome.  N Engl J Med. 2004;  351 327-336
  • 40 Habashi N M. Other approaches to open-lung ventilation: airway pressure release ventilation.  Crit Care Med. 2005;  33(Suppl 3) S228-S240
  • 41 Stock M C, Downs J B, Frolicher D A. Airway pressure release ventilation.  Crit Care Med. 1987;  15 462-466
  • 42 Putensen C, Zech S, Wrigge H et al.. Long term effects of spontaneous breathing during ventilatory support in patients with ALI.  Am J Resp Crit Care Med. 2001;  164 43-49
  • 43 Froese A B, Bryan C. High-frequency ventilation.  Am Rev Respir Dis. 1987;  135 1363-1374
  • 44 Chang H K. Mechanisms of gas transport during high frequency ventilation.  J Appl Physiol. 1984;  56 553-563
  • 45 MacIntyre N R. High frequency ventilation. In: Tobin M Mechanical Ventilation: Principles and Practice. New York; McGraw-Hill 1994
  • 46 Froese A B. High frequency oscillatory ventilation for ARDS: lets get it right this time.  Crit Care Med. 1997;  25 906-908
  • 47 Mehta S, Granton J, MacDonald R J et al.. High-frequency oscillatory ventilation in adults: the Toronto experience.  Chest. 2004;  126 518-527
  • 48 Bollen C W, Viterwaal C S, van Vught A J et al.. Cumulative meta-analysis of high frequency vs. conventional ventilation in premature neonates.  Am J Respir Crit Care Med. 2003;  168 1150
  • 49 Froese A B, Kinsella J P. High-frequency oscillatory ventilation: lessons from the neonatal/pediatric experience.  Crit Care Med. 2005;  33(Suppl 3) S115-S121
  • 50 Derdak S, Mehta S, Stewart T E et al.. Multicenter Oscillatory Ventilation for Acute Respiratory Distress Syndrome Trial (MOAT) Study Investigators. High-frequency oscillatory ventilation for acute respiratory distress syndrome in adults: a randomized, controlled trial.  Am J Respir Crit Care Med. 2002;  166 801-808
  • 51 ACCP/AARC/SCCM Task Force . Evidence-based guidelines for weaning and discontinuing mechanical ventilatory support.  Chest. 2001;  120(suppl 6) S1-S146 , Also in Respir Care 2002;47:20-35

Neil MacIntyreM.D. 

Pulmonary, Allergy, and Critical Care, Duke University Medical Center

DUMC 3911, Durham, NC 27710

Email: neil.macintyre@duke.edu