Tidal volume, positive end-expiratory pressure, and mortality in acute respiratory distress syndrome

Fifty Years of Research in ARDS. Vt Selection in Acute Respiratory Distress Syndrome

Mechanical ventilation (MV) is critical in the management of many patients with acute respiratory distress syndrome (ARDS). However, MV can also cause ventilator-induced lung injury (VILI). The selection of an appropriate Vt is an essential part of a lung-protective MV strategy. Since the publication of a large randomized clinical trial demonstrating the benefit of lower Vts, the use of Vts of 6 ml/kg predicted body weight (based on sex and height) has been recommended in clinical practice guidelines. However, the predicted body weight approach is imperfect in patients with ARDS because the amount of aerated lung varies considerably due to differences in inflammation, consolidation, flooding, and atelectasis. Better approaches to setting Vt may include limits on end-inspiratory transpulmonary pressure, lung strain, and driving pressure. The limits of lowering Vt have not yet been established, and some patients may benefit from Vts that are lower than those in current use. However, lowering Vts may result in respiratory acidosis. Tactics to reduce respiratory acidosis include reductions in ventilation circuit dead space, increases in respiratory rate, higher positive end-expiratory pressures in patients who recruit lung in response to positive end-expiratory pressure, recruitment maneuvers, and prone positioning. Mechanical adjuncts such as extracorporeal carbon dioxide removal may be useful to normalize pH and carbon dioxide levels, but further studies will be necessary to demonstrate benefit with this technology.

[Mechanotransduction and the bronchoalveolar epithelium]

The bronchoalveolar epithelium is submitted to numerous mechanical strains. These strains induce a specific cellular activity at the tissue level. This type of activation has been studied in respiratory medicine, mainly in the context of mechanical ventilation and asthma. The phenomenon of mechanotransduction is linked to various epithelial cellular activities such as epithelium repair, extracellular matrix remodelling, inflammatory mediator release and mucociliary regulation. In this review, the main studies related to bronchoalveolar epithelial mechanotransduction are reported to bring a new perspective on this little known biological phenomenon. A better understanding of the physiological and pathological aspects will potentially offer new treatment approaches for bronchial diseases.

Epithelial sodium channels in the adult lung--important modulators of pulmonary health and disease

Absorption of excess fluid from the airways and alveolar lumen requires active vectorial transepithelial transport of sodium ions (Na+) by alveolar type II and possibly type I cells. The rate-limiting step in this process is the activity of the heterotrimeric apical membrane epithelial Na+ channel (ENaC). Pharmacologic inhibitors and genetic manipulations that disrupt Na+ transport result in fluid accumulation within the lung and failure of gas exchange. The importance of Na+ transport in the lung is also demonstrated in conditions such as ARDS, where abnormal absorption of Na+ contributes to the pathophysiology of pulmonary disease. ENaC expression and function is influenced by diverse factors, such as oxygen tension, glucocorticoids, and cytoskeletal proteins. In addition, ENaC dysfunction has been shown to be induced by purinergic nucleotide activation of P2Y receptors (in paramyxoviral bronchiolitis) and reactive species (in acute lung injury). Finally, beta-adrenergic agonists have been shown experimentally to reverse defects in ENaC function, and improve hypoxemia and pulmonary edema, and may provide a novel therapeutic modality for ARDS, although some viral lung pathogens appear to induce insensitivity to their actions.

Acute lung injury and the acute respiratory distress syndrome: a clinical review

Acute respiratory distress syndrome and acute lung injury are well defined and readily recognised clinical disorders caused by many clinical insults to the lung or because of predispositions to lung injury. That this process is common in intensive care is well established. The mainstay of treatment for this disorder is provision of excellent supportive care since these patients are critically ill and frequently have coexisting conditions including sepsis and multiple organ failure. Refinements in ventilator and fluid management supported by data from prospective randomised trials have increased the methods available to effectively manage this disorder.

Mechanical ventilation in sepsis-induced acute lung injury/acute respiratory distress syndrome: an evidence-based review

OBJECTIVE

In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for mechanical ventilation in sepsis-induced acute lung injury/acute respiratory distress syndrome (ARDS) that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis.

DESIGN

The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee.

METHODS

The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591.

CONCLUSION

A minimum amount of positive end-expiratory pressure should be set to prevent lung collapse at end expiration in ARDS. Setting the level of positive end-expiratory pressure may be guided by Fio2 requirement or measurement of thoracopulmonary compliance. Role of noninvasive positive-pressure ventilation in acute lung injury/ARDS is undefined. Small tidal volume ventilation and limitation of end-inspiratory plateau pressure is important in the management of ARDS and may be facilitated by permissive hypercapnia. Prone positioning should be considered in the severest of ARDS patients. The ideal fluid management strategy in ARDS is unknown. Weaning protocols should be in place that include spontaneous breathing trials and criteria for initiating such trials. The role of high-frequency oscillatory ventilation and airway pressure release ventilation in ARDS is uncertain.