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Vol 48, No 5 (2016)
Review articles
Published online: 2016-12-19
Submitted: 2016-06-16
Accepted: 2016-11-09
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Early severe acute respiratory distress syndrome: What’s going on? Part II: controlled vs. spontaneous ventilation?

Fabrice Petitjeans, Cyrille Pichot, Marco Ghignone, Luc Quintin
DOI: 10.5603/AIT.2016.0057
·
Pubmed: 28000205
·
Anaesthesiol Intensive Ther 2016;48(5):339-351.

open access

Vol 48, No 5 (2016)
Review articles
Published online: 2016-12-19
Submitted: 2016-06-16
Accepted: 2016-11-09

Abstract

The second part of this overview on early severe ARDS delineates the pros and cons of the following: a) controlled mechanical ventilation (CMV: lowered oxygen consumption and perfect patient-to-ventilator synchrony), to be used during acute cardio-ventilatory distress in order to “buy time” and correct circulatory insufficiency and metabolic defects (acidosis, etc.); b) spontaneous ventilation (SV: improved venous return, lowered intrathoracic pressure, absence of muscle atrophy). Given a stabilized early severe ARDS, as soon as the overall clinical situation improves, spontaneous ventilation will be used with the following stringent conditionalities: upfront circulatory optimization, upright positioning, lowered VO2, lowered acidotic and hypercapnic drives, sedation without ventilatory depression and without lowered muscular tone, as well as high PEEP (titrated on transpulmonary pressure, or as a second best: “trial”-PEEP) with spontaneous ventilation + pressure support (or newer modes of ventilation). As these propositions require evidence-based demonstration, the reader is reminded that the accepted practice remains, in 2016, controlled mechanical ventilation, muscle relaxation and prone position.

Abstract

The second part of this overview on early severe ARDS delineates the pros and cons of the following: a) controlled mechanical ventilation (CMV: lowered oxygen consumption and perfect patient-to-ventilator synchrony), to be used during acute cardio-ventilatory distress in order to “buy time” and correct circulatory insufficiency and metabolic defects (acidosis, etc.); b) spontaneous ventilation (SV: improved venous return, lowered intrathoracic pressure, absence of muscle atrophy). Given a stabilized early severe ARDS, as soon as the overall clinical situation improves, spontaneous ventilation will be used with the following stringent conditionalities: upfront circulatory optimization, upright positioning, lowered VO2, lowered acidotic and hypercapnic drives, sedation without ventilatory depression and without lowered muscular tone, as well as high PEEP (titrated on transpulmonary pressure, or as a second best: “trial”-PEEP) with spontaneous ventilation + pressure support (or newer modes of ventilation). As these propositions require evidence-based demonstration, the reader is reminded that the accepted practice remains, in 2016, controlled mechanical ventilation, muscle relaxation and prone position.

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Keywords

acute respiratory distress syndrome, ARDS, severe ARDS; acute hypoxic non-hypercapnic respiratory failure; driving pressure; tidal volume, Vt, low tidal volume, ultra-low tidal volume; positive end-expiratory pressure, PEEP; transpulmonary pressure; contr

About this article
Title

Early severe acute respiratory distress syndrome: What’s going on? Part II: controlled vs. spontaneous ventilation?

Journal

Anaesthesiology Intensive Therapy

Issue

Vol 48, No 5 (2016)

Pages

339-351

Published online

2016-12-19

DOI

10.5603/AIT.2016.0057

Pubmed

28000205

Bibliographic record

Anaesthesiol Intensive Ther 2016;48(5):339-351.

Keywords

acute respiratory distress syndrome
ARDS
severe ARDS
acute hypoxic non-hypercapnic respiratory failure
driving pressure
tidal volume
Vt
low tidal volume
ultra-low tidal volume
positive end-expiratory pressure
PEEP
transpulmonary pressure
contr

Authors

Fabrice Petitjeans
Cyrille Pichot
Marco Ghignone
Luc Quintin

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