Abstract
Many animal studies have shown that high peak inspiratory pressures (PIP) during mechanical ventilation can induce acute lung injury with hyaline membranes. Since 1984 we have limited PIP in patients with ARDS by reducing tidal volume, allowing spontaneous breathing with SIMV and disregarding hypercapnia. Since 1987 50 patients with severe ARDS with a “lung injury score” ≥2.5 and a mean PaO2/FiO2 ratio of 94 were managed in this manner. The mean maximum PaCO2 was 62 mmHg, the highest being 129 mmHg. The hospital mortality was significantly lower than that predicted by Apache II (16% vs. 39.6%,x 2=11.64,p<0.001). Only one death was due to respiratory failure, caused by pneumocystis pneumonia. 10 patients had a “ventilator score” >80, which has previously predicted 100% mortality from respiratory failure. Only 2 died, neither from respiratory failure. There was no significant difference in lung injury score, ventilator score, PaO2/FiO2 or maximum PaCO2 between survivors and non-survivors. We suggest that this ventilatory management may substantially reduce mortality in ARDS, particularly from respiratory failure.
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Lachmann B, Jonson B, Lindroth M, Robertson B (1982) Modes of artificial ventilation in severe respiratory distress syndrome. Lung function and morphology in rabbits after wash-out of alveolar surfactant. Crit Care Med 10:724–732
Hamilton PP, Onayemi A, Smith JA, Gillan JE, Cutz E, Froese AB, Bryan AC (1983) Comparison of conventional and high frequency ventilation: oxygenation and lung pathology. J Appl Physiol 55:131–138
Parker JC, Townsley MI, Rippe B, Taylor AE, Thigpen J (1984) Increased microvascular permeability in dog lungs due to high peak airway pressures. J Appl Physiol 56:1809–1816
Dreyfuss D, Basset G, Soler P, Saumon G (1985) Intermittent positive-pressure hyperventilation with high inflation pressures produces pulmonary microvascular injury in rats. Am Rev Respir Dis 132:880–884
Kolobow T, Morett MP, Fumagali R, Mascheroni D, Prato P, Chen V, Joris M (1987) Severe impairment in lung function induced by high peak airway pressure during mechanical ventilation. An experimemal study. Am Rev Respir Dis 135:312–315
Kawano T, Mori S, Cybulsky M, Burger R, Ballin A, Cutz E, Bryan AC (1987) Effect of granulocyte depletion in a ventilated surfactant-depleted lung. J Appl Physiol 62:27–33
McCulloch PR, Forkert PG, Froese AB (1988) Lung volume maintainance prevents lung injury during high frequency oscillation in surfactant-deficient rabbits. Am Rev Respir Dis 137:1185–1192
Sandhar BK, Niblett DJ, Argiras EP, Dunhill MS, Sykes MK (1988) Effects of positive end-expiratory pressure on hyaline membrane formation in a rabbit model of the neonatal respiratory distress syndrome. Intensive Care Med 14:538–546
Dorrington KL, McRae KM, Gardaz JP, Dunhill MS, Sykes MK, Wilkinson AR (1989) A randomised comparison of total extracorporeal CO2 removal with conventional mechanical ventilation in experimental hyaline membrane disease. Intensive Care Med 15:184–191
Solca M, Kolobow T, Huang HH, Chen V, Buckhold DK, Pierce JE (1984) Respiratory distress syndrome in immature lambs. Prevention through accelerated conditioning of the lung. Am Rev Respir Dis 129:979–984
Pesenti A, Kolobow T, Buckhold D, Pierce JE, Huang H, Chen V (1982) Prevention of hyaline membrane disease in foetal lambs by apnoeic oxygenation and extracorporeal CO2 removal. Intensive Care Med 8:11–17
Gattinoni L, Pesenti A, Caspani L, Pelizzola A, Mascheroni D, Marcolin R, Iapichino G, Langer M, Agostoni A, Kolobow T, Melrose DG, Damia G (1984) The role of static lung compliance in the management of severe ARDS unresponsive to conventional treatment. Intensive Care Med 10:121–126
Gattinoni L, Pesenti A, Avalli L, Rossi F, Bombino M (1987) Pressure-volume curve of total respiratory system in acute respiratory failure. Computed tomographic study. Am Rev Respir Dis 136:730–736
Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) Apache II: a severity of disease classification system. Crit Care Med 13:818–829
Prys-Roberts C, Kelman GR, Nunn JR (1966) Determination of the in vivo carbon dioxide titration curve of anaesthetised man. Br J Anaesth 38:500–509
Murray JF, Mathay MA, Luce JM, Flick M (1988) An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis 138:720–723
Smith PEM, Gordon IJ (1986) An index to predict outcome in adult respiratory distress syndrome. Intensive Care Med 12:86–89
Goris RJ, Boekhorst TPA, Nuytinck JKS, Gimbrere JSF (1985) Multiple-organ failure. Generalised autodestructive inflammation? Arch Surg 120:1109–1115
Petty TL (1987) CO2 can be good for you. Respir Management 17:7–66
Montgomery AB, Stager MA, Carrico CJ, Hudson LD (1985) Causes of mortality in patients with the adult respiratory distress syndrome. Am Rev Respir Dis 132:485–489
Rinaldo JE (1986) The prognosis of the adult respiratory distress syndrome. Inappropriate pessimism? Chest 90:470–471
Gillespie DJ, Marsh HMM, Divertie MB, Meadows JA (1986) Clinical outcome of respiratory failure in patients requiring prolonged (>24 h) mechanical ventilation. Chest 90:364–369
Danek SJ, Lynch JP, Weg JG, Danzker DR (1980) The dependence of oxygen uptake on oxygen delivery in the adult respiratory distress syndrome. Am Rev Respir Dis 122:387–395
Kariman K, Burns SR (1985) Regulation of tissue oxygen extraction is disturbed in adult respiratory distress syndrome. Am Rev Respir Dis 132:109–114
Bihari D, Smithies M, Gimson A, Tinker J (1987) The effects of vasodilation with prostacyclin on oxygen delivery and uptake in critically ill patients. N Engl J Med 317:397–403
Hickling KG, Howard R (1988) A retrospective survey of treatment and mortality in aspiration pneumonia. Intensive Care Med 14:617–622
Prewitt RM, McCarthy J, Wood LDH (1981) Treatment of low pressure pulmonary oedema in dogs. Relative effects of hydrostatic and oncotic pressure, nitroprusside, and positive end-expiratory pressure. J Clin Invest 67:409–418
Simmons RS, Berdine GG, Seidenfeld JJ, Prihoda TJ, Harris GD, Smith JD, Gilbert TJ, Mota E, Johanson WG (1987) Fluid balance and the adult respiratory distress syndrome. Am Rev Respir Dis 135:924–929
Andersen JB (1987) Inverse I: E ratio ventilation with pressure control in catastrophic lung disease in adults. Intensive Care World 4:21–23
Tharratt RS, Allen RP, Albertson TE (1988) Pressure controlled inverse ratio ventilation in severe adult respiratory failure. Chest 94:755–762
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Hickling, K.G., Henderson, S.J. & Jackson, R. Low mortality associated with low volume pressure limited ventilation with permissive hypercapnia in severe adult respiratory distress syndrome. Intensive Care Med 16, 372–377 (1990). https://doi.org/10.1007/BF01735174
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DOI: https://doi.org/10.1007/BF01735174