3 years ago

50 Years of Research in ARDS. Tidal Volume Selection in the Acute Respiratory Distress Syndrome.

Mechanical ventilation (MV) is critical in the management of many patients with the acute respiratory distress syndrome (ARDS). However, MV can also cause ventilator-induced lung injury (VILI). The selection of an appropriate tidal volume is an essential part of a lung-protective MV strategy. Since the publication of a large randomized clinical trial demonstrating the benefit of lower tidal volumes, the use of tidal volumes of 6 mL/kg predicted body weight (PBW, based on sex and height) has been recommended in clinical practice guidelines. However, the PBW approach is imperfect in ARDS patients because the amount of aerated lung varies considerably due to differences in inflammation, consolidation, flooding, and atelectasis. Better approaches to setting tidal volume may include limits on end-inspiratory transpulmonary pressure, lung strain, and driving pressure. The limits of lowering tidal volume have not yet been established, and some patients may benefit from tidal volumes that are lower than those in current use. However, lowering tidal volumes 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 (PEEP) in patients who recruit lung in response to PEEP, 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.

Publisher URL: http://doi.org/10.1164/rccm.201708-1629CI

DOI: 10.1164/rccm.201708-1629CI

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