Chest
Volume 131, Issue 3, March 2007, Pages 921-929
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Postgraduate Education Corner: Contemporary Reviews in Critical Care Medicine
Mechanical Ventilation in ARDS: A State-of-the-Art Review

https://doi.org/10.1378/chest.06-1515Get rights and content

Abstract

Mechanical ventilation is an essential component of the care of patients with ARDS, and a large number of randomized controlled clinical trials have now been conducted evaluating the efficacy and safety of various methods of mechanical ventilation for the treatment of ARDS. Low tidal volume ventilation (≤ 6 mL/kg predicted body weight) should be utilized in all patients with ARDS as it is the only method of mechanical ventilation that, to date, has been shown to improve survival. High positive end-expiratory pressure, alveolar recruitment maneuvers, and prone positioning may each be useful as rescue therapy in a patient with severe hypoxemia, but these methods of ventilation do not improve survival for the wide population of patients with ARDS. Although not specific to the treatment of ARDS, protocol-driven weaning that utilizes a daily spontaneous breathing trial and ventilation in the semirecumbent position have proven benefits and should be used in the management of ARDS patients.

Section snippets

Low Tidal Volume Ventilation

Early interest in low tidal volume ventilation was prompted by animal studies3, 4showing that ventilation with large tidal volumes and high inspiratory pressures resulted in the development of ALI characterized by hyaline membranes and inflammatory infiltrates. While tidal volumes of 10 to 15 mL/kg had traditionally been used in the majority of patients with respiratory failure,5it was recognized in the mid-1980s that ARDS resulted in a significant reduction in the amount of normally aerated

High PEEP and Alveolar Recruitment

PEEP is an essential component of mechanical ventilation for patients with ARDS that should be utilized to increase the proportion of nonaerated lung, resulting in improved oxygenation. Traditionally, PEEP values of 5 to 12 cm H2O have been used in the ventilation of patients with ARDS.34However, it currently remains unclear whether these values are ideal since randomized trials14, 35, 36have not shown that higher levels of PEEP lead to a reduction in mortality rate.

Early observations that PEEP

Prone Positioning

Mechanical ventilation in the prone position was first proposed in 1974 by Bryan,40who suggested that the procedure would result in better expansion of the dorsal lung regions, thus improving oxygenation. Shortly thereafter, two nonrandomized studies41, 42reported the successful use of prone positioning as an adjunct to mechanical ventilation for the treatment of ARDS, with patients experiencing improved oxygenation. In the 3 decades following these initial reports, interest in prone

Alternative Modes/Methods of Mechanical Ventilation

Both large trials conducted by the ARDS Network utilized the volume assist/control mode of ventilation. In fact, this was the only mode of ventilation used in each of the three randomized controlled trials of ARDS in which the intervention significantly reduced mortality.10, 14, 35Although the efficacy of low tidal volume ventilation is not necessarily contingent on the use of the volume assist/control mode of ventilation, it continues to be the recommended mode in the general population of

Liberation From Mechanical Ventilation

As the majority of patients who are mechanically ventilated for acute respiratory failure spend approximately two thirds of their time on the ventilator in the “weaning” period,34a systematic, evidence-based approach to liberating ARDS patients from mechanical ventilation is an essential component of their care. This approach should be protocol-directed, and a daily spontaneous breathing trial should be the central component of that protocol.

Several randomized controlled trials60, 61, 62have

Conclusion

In the management of patients with ARDS, low tidal volume ventilation (ie, ≤ 6 mL/kg predicted body weight) with the maintenance of plateau pressures of < 30 cm H2O, when possible, remains the standard of care as it is the only method of mechanical ventilation that has been proven to reduce the mortality rate. While modifications of these parameters could result in even better outcomes than those observed in the ARMA and ALVEOLI trials (Fig 2), randomized controlled trials should be performed

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    The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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