Ten golden rules for individualized mechanical ventilation in acute respiratory distress syndrome

Abstract

Considerable progress has been made over the last decades in the management of acute respiratory distress syndrome (ARDS). Mechanical ventilation(MV) remains the cornerstone of supportive therapy for ARDS. Lung-protective MV minimizes the risk of ventilator-induced lung injury (VILI) and improves survival. Several parameters contribute to the risk of VILI and require careful setting including tidal volume (V_T), plateau pressure (P_plat), driving pressure (ΔP), positive end-expiratory pressure (PEEP), and respiratory rate. Measurement of energy and mechanical power allows quantification of the relative contributions of various parameters (V_T, P_plat, ΔP, PEEP, respiratory rate, and airflow) for the individualization of MV settings. The use of neuromuscular blocking agents mainly in cases of severe ARDS can improve oxygenation and reduce asynchrony, although they are not known to confer a survival benefit. Rescue respiratory therapies such as prone positioning, inhaled nitric oxide, and extracorporeal support techniques may be adopted in specific situations. Furthermore, respiratory weaning protocols should also be considered. Based on a review of recent clinical trials, we present 10 golden rules for individualized MV in ARDS management.

Keywords: Acute respiratory distress syndrome (ARDS); Extracorporeal CO2 removal (ECCO2R); Extracorporeal membrane oxygenation (ECMO); Protective mechanical ventilation.

Fig. 1

Proposed algorithm for NMBAs use in ARDS patients. NMBA use is suggested when moderate to severe ARDS is present. NMBAs plays a pivotal role in limiting decruitment and maintaining PEEP, allowing a reduction in swings of transpulmonary pressure due to strong inspiratory effort and expiratory alveolar collapse. ARDS: Acute respiratory distress syndrome; BGA: Blood gas analysis; BIS: Bispectral index; ICU: Intensive care unit; NMBA: Neuromuscular blocking agent; PBW: Predicted body weight; PEEP: Positive end-expiratory pressure; RASS: Richmond Agitation Sedation Scale.

Fig. 2

Proposed algorithm for rescue strategies. ECCO₂R: Extracorporeal CO₂ removal; FiO₂: Fraction of inspired oxygen; iNO: Inhaled nitric oxide; PaCO₂: Partial pressure of carbon dioxide; PaO₂: Partial pressure of oxygen; VV-ECMO: Venous-venous extracorporeal membrane oxygenation.

Fig. 3

Simplified formulas for mechanical power (MP) for volume-controlled and pressure-controlled ventilation. A: Mechanical power formula for volume-control ventilation. B: Mechanical power formula for pressure-controlled ventilation. Elastic static, dynamic, and resistive forces in yellow, blue, and green, respectively. MP: Mechanical power; PCV: Pressure-controlled ventilation; PEEP: Positive end-expiratory pressure; P peak: Peak pressure; P_plat: Plateau pressure; RR: Respiratory rate; VCV: Volume-controlled ventilation; V_T: Tidal volume. Modified from Giosa et al. .