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Critical Care
Published in Vincenzo Berghella, Maternal-Fetal Evidence Based Guidelines, 2022
Jaimie Maines, Lauren A. Plante
Positive-pressure ventilation is the mainstay of treatment for ARDS, but may cause further damage to the lung through barotrauma, volutrauma, and atelectrauma. After the publication of the ARDSNet trial in 2000, which demonstrated better survival with low-tidal-volume ventilation [120], strategies for mechanical ventilation changed from normalizing arterial blood gases to limiting ventilator-induced lung injury. This lower-tidal-volume strategy allows hypercapnia and respiratory acidosis while minimizing inflation pressures and stretch-induced lung injury. In the ARDSNet multicenter randomized controlled trial, the use of lower tidal volumes in mechanical ventilation (6 ml/kg predicted body weight vs. 12 ml/kg) was associated with lower mortality and more ventilator-free days in non-pregnant adults [120] in a general medical-surgical ICU population.
Ards Treatment
Published in Stephen M. Cohn, Alan Lisbon, Stephen Heard, 50 Landmark Papers, 2021
Bruck Or, Kodela Jennifer, Kopec Scott
In the 1980s and 1990s, chest CT scans demonstrated that the pathologic process of ARDS was quite heterogeneous, with some areas of the lung affected, whereas other areas appeared to be free of disease. Those disease-free areas would have normal or near-normal compliance and would be more likely to be inflated during inspiration compared to diseased areas. Using supraphysiologic tidal volumes would damage those normal lung areas and worsen lung function. This lung injury would ultimately be termed ventilator-induced lung injury (VILI) and felt to be a consequence of both volutrauma from large tidal volumes and atelectrauma from repeated opening and closing of the already fragile terminal airways.
Emergency Medicine
Published in Stephan Strobel, Lewis Spitz, Stephen D. Marks, Great Ormond Street Handbook of Paediatrics, 2019
Although there are no trial data to support the use of high frequency oscillatory ventilation HFOV, it is still often used for patients with ARDS because it delivers small tidal volumes (typically 2 ml/kg) and may prevent ‘atelectotrauma’, keep the lungs open, improve alveolar recruitment and improve ventilation/perfusion matching.
The acute respiratory distress syndrome
Published in Baylor University Medical Center Proceedings, 2020
Christopher Wood, Vivek Kataria, Ariel M. Modrykamien
In a normal healthy lung, fluid movement is regulated to keep the alveoli dry and hold on to a small amount of interstitial fluid. Lung injury, such as ARDS, disrupts this regulatory process, resulting in diffuse alveolar damage.17 One form of ventilator-induced injury, referred to as “biotrauma,” can happen in both healthy and injured lungs.18 It causes a systemic inflammatory response releasing a cascade of cytokines.18 Three general regions of the lung have been described in ARDS: normal lung tissue, densely consolidated lung, and a collapsible region during expiration that is recruitable during inspiration.19 In the absence of optimal PEEP, this collapsible/recruitable region of the lung can form an injury known as “atelectrauma” due to the repeated opening and closing of the airway and alveoli.20 Proposed methods to determine optimal PEEP will be discussed further.
Microvesicles as new therapeutic targets for the treatment of the acute respiratory distress syndrome (ARDS)
Published in Expert Opinion on Therapeutic Targets, 2019
Sanooj Soni, Nikhil Tirlapur, Kieran P. O’Dea, Masao Takata, Michael R. Wilson
Currently, treatment for ARDS consists almost entirely of supportive care, of which mechanical ventilation is paramount. Conflictingly, however, ventilation produces or exacerbates lung injury resulting in so-called ‘ventilator-induced lung injury’ (VILI). Modern ventilatory strategies are therefore designed around the concept of ‘lung-protective ventilation’ to reduce VILI. Lowering tidal volumes and limiting plateau airway pressures to 30cmH2O has been shown to significantly reduce mortality by decreasing volutrauma (application of high tidal volumes resulting in lung over-stretching) and barotrauma (application of high pressures to the lung) [8]. Moreover, within animal models high pressure/tidal volume mechanical ventilation alone has been shown to induce rapid activation of alveolar macrophages, endothelial and epithelial cells [9], upregulation of inflammatory mediators, and promotion of both the recruitment and activation of ‘marginated’ neutrophils and inflammatory monocytes within the pulmonary microvasculature [10,11]. Ventilated patients are also at increased risk of atelectrauma (collapse and reopening of lung units) [4]. Ventilatory measures to reduce atelectrauma include the use of higher PEEP, although the benefits of this seem dependent on patient-specific factors [12] rather than being applicable to the general ARDS population [8].
Emerging approaches in pediatric mechanical ventilation
Published in Expert Review of Respiratory Medicine, 2019
Duane C Williams, Ira M Cheifetz
Even with adjustments in ventilator settings and modes of ventilation, ventilator-induced lung injury (baro-, atelec-, and volu-trauma) may exist. As ARDS is a heterogeneous disease, areas of lung parenchyma may transition between hyperinflation, normal aeration, and collapse; thus, careful adjustment of ventilator settings and modes as lung condition changes is vital to achieving the best outcomes [25,45]. At elevated levels of peak inspiratory, plateau and/or mean airway pressure, providers may consider high-frequency oscillatory ventilation (HFOV) to decrease the pressure swings potentially associated with alveolar trauma. The theoretical advantage of HFOV is the maintenance of an open lung model with the use of a higher mean airway pressure but low phasic volume and pressure changes to maintain the alveoli open between the lower and upper inflection points [46]. Such an approach may limit lung trauma (atelectrauma) caused by the opening and closing of the lung to deliver a tidal volume and lung overdistention (volutrauma), especially in the presence of poor compliance [47].