Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Mechanical ventilation of adults in acute respiratory distress syndrome

INTRODUCTION

Ventilator-associated lung injury may be an important cause of poor clinical outcomes in patients with acute respiratory distress syndrome (ARDS). As a result, strategies of mechanical ventilation that reduce the incidence and severity of ventilator-associated lung injury are being sought. The mechanical ventilatory strategies known as low tidal volume ventilation, open lung ventilation, and high positive end-expiratory pressure (high PEEP) are reviewed here. In addition, recruitment maneuvers and titration of PEEP are described.

The Berlin Definition of ARDS (published in 2012) has replaced the American-European Consensus Conference’s definition of ARDS (published in 1994) [1,2]. However, it should be recognized that most evidence is based upon prior definitions. The current diagnostic criteria for ARDS are provided separately. (See "Acute respiratory distress syndrome: Clinical features and diagnosis in adults", section on 'Diagnostic criteria'.)

Epidemiology, etiology, pathogenesis, clinical features, diagnosis, prognosis, outcomes, and non-mechanical ventilation related aspects of management are discussed separately. (See "Acute respiratory distress syndrome: Clinical features and diagnosis in adults" and "Acute respiratory distress syndrome: Epidemiology, pathophysiology, pathology, and etiology in adults" and "Acute respiratory distress syndrome: Supportive care and oxygenation in adults" and "Acute respiratory distress syndrome: Novel therapies in adults" and "Acute respiratory distress syndrome: Prognosis and outcomes in adults".)

LOW TIDAL VOLUME VENTILATION

Low tidal volume ventilation (LTVV) is also referred to as lung protective ventilation. The rationale for this approach is that smaller tidal volumes are less likely to generate alveolar overdistension, one of the principal causes of ventilator-associated lung injury. (See "Ventilator-associated lung injury", section on 'Pathogenesis'.)

Benefit — The preponderance of evidence suggests that LTVV improves mortality, as well as other clinically important outcomes in patients with ARDS [3-5]:

                         

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2014. | This topic last updated: May 5, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Bernard GR, Artigas A, Brigham KL, et al. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994; 149:818.
  2. Artigas A, Bernard GR, Carlet J, et al. The American-European Consensus Conference on ARDS, part 2: Ventilatory, pharmacologic, supportive therapy, study design strategies, and issues related to recovery and remodeling. Acute respiratory distress syndrome. Am J Respir Crit Care Med 1998; 157:1332.
  3. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000; 342:1301.
  4. Putensen C, Theuerkauf N, Zinserling J, et al. Meta-analysis: ventilation strategies and outcomes of the acute respiratory distress syndrome and acute lung injury. Ann Intern Med 2009; 151:566.
  5. Petrucci N, De Feo C. Lung protective ventilation strategy for the acute respiratory distress syndrome. Cochrane Database Syst Rev 2013; 2:CD003844.
  6. Needham DM, Colantuoni E, Mendez-Tellez PA, et al. Lung protective mechanical ventilation and two year survival in patients with acute lung injury: prospective cohort study. BMJ 2012; 344:e2124.
  7. Kregenow DA, Rubenfeld GD, Hudson LD, Swenson ER. Hypercapnic acidosis and mortality in acute lung injury. Crit Care Med 2006; 34:1.
  8. de Durante G, del Turco M, Rustichini L, et al. ARDSNet lower tidal volume ventilatory strategy may generate intrinsic positive end-expiratory pressure in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2002; 165:1271.
  9. Hough CL, Kallet RH, Ranieri VM, et al. Intrinsic positive end-expiratory pressure in Acute Respiratory Distress Syndrome (ARDS) Network subjects. Crit Care Med 2005; 33:527.
  10. Kallet RH, Campbell AR, Dicker RA, et al. Effects of tidal volume on work of breathing during lung-protective ventilation in patients with acute lung injury and acute respiratory distress syndrome. Crit Care Med 2006; 34:8.
  11. Kahn JM, Andersson L, Karir V, et al. Low tidal volume ventilation does not increase sedation use in patients with acute lung injury. Crit Care Med 2005; 33:766.
  12. Pohlman MC, McCallister KE, Schweickert WD, et al. Excessive tidal volume from breath stacking during lung-protective ventilation for acute lung injury. Crit Care Med 2008; 36:3019.
  13. Terragni PP, Rosboch G, Tealdi A, et al. Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome. Am J Respir Crit Care Med 2007; 175:160.
  14. Chiumello D, Carlesso E, Cadringher P, et al. Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome. Am J Respir Crit Care Med 2008; 178:346.
  15. Hager DN, Krishnan JA, Hayden DL, et al. Tidal volume reduction in patients with acute lung injury when plateau pressures are not high. Am J Respir Crit Care Med 2005; 172:1241.
  16. Mikkelsen ME, Christie JD, Lanken PN, et al. The adult respiratory distress syndrome cognitive outcomes study: long-term neuropsychological function in survivors of acute lung injury. Am J Respir Crit Care Med 2012; 185:1307.
  17. Umoh NJ, Fan E, Mendez-Tellez PA, et al. Patient and intensive care unit organizational factors associated with low tidal volume ventilation in acute lung injury. Crit Care Med 2008; 36:1463.
  18. Richecoeur J, Lu Q, Vieira SR, et al. Expiratory washout versus optimization of mechanical ventilation during permissive hypercapnia in patients with severe acute respiratory distress syndrome. Am J Respir Crit Care Med 1999; 160:77.
  19. Prin S, Chergui K, Augarde R, et al. Ability and safety of a heated humidifier to control hypercapnic acidosis in severe ARDS. Intensive Care Med 2002; 28:1756.
  20. Broccard AF, Hotchkiss JR, Vannay C, et al. Protective effects of hypercapnic acidosis on ventilator-induced lung injury. Am J Respir Crit Care Med 2001; 164:802.
  21. Sinclair SE, Kregenow DA, Lamm WJ, et al. Hypercapnic acidosis is protective in an in vivo model of ventilator-induced lung injury. Am J Respir Crit Care Med 2002; 166:403.
  22. Broccard AF. Respiratory acidosis and acute respiratory distress syndrome: time to trade in a bull market? Crit Care Med 2006; 34:229.
  23. Amato MB, Barbas CS, Medeiros DM, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 1998; 338:347.
  24. Villar J, Kacmarek RM, Pérez-Méndez L, Aguirre-Jaime A. A high positive end-expiratory pressure, low tidal volume ventilatory strategy improves outcome in persistent acute respiratory distress syndrome: a randomized, controlled trial. Crit Care Med 2006; 34:1311.
  25. Huh JW, Jung H, Choi HS, et al. Efficacy of positive end-expiratory pressure titration after the alveolar recruitment manoeuvre in patients with acute respiratory distress syndrome. Crit Care 2009; 13:R22.
  26. Gattinoni L, Pelosi P, Crotti S, Valenza F. Effects of positive end-expiratory pressure on regional distribution of tidal volume and recruitment in adult respiratory distress syndrome. Am J Respir Crit Care Med 1995; 151:1807.
  27. Malbouisson LM, Muller JC, Constantin JM, et al. Computed tomography assessment of positive end-expiratory pressure-induced alveolar recruitment in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2001; 163:1444.
  28. Ranieri VM, Eissa NT, Corbeil C, et al. Effects of positive end-expiratory pressure on alveolar recruitment and gas exchange in patients with the adult respiratory distress syndrome. Am Rev Respir Dis 1991; 144:544.
  29. Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 2004; 351:327.
  30. Mercat A, Richard JC, Vielle B, et al. Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2008; 299:646.
  31. Meade MO, Cook DJ, Guyatt GH, et al. Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2008; 299:637.
  32. Briel M, Meade M, Mercat A, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA 2010; 303:865.
  33. Santa Cruz R, Rojas JI, Nervi R, et al. High versus low positive end-expiratory pressure (PEEP) levels for mechanically ventilated adult patients with acute lung injury and acute respiratory distress syndrome. Cochrane Database Syst Rev 2013; 6:CD009098.
  34. Gattinoni L, Caironi P, Cressoni M, et al. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med 2006; 354:1775.
  35. Slutsky AS, Hudson LD. PEEP or no PEEP--lung recruitment may be the solution. N Engl J Med 2006; 354:1839.
  36. Caironi P, Cressoni M, Chiumello D, et al. Lung opening and closing during ventilation of acute respiratory distress syndrome. Am J Respir Crit Care Med 2010; 181:578.
  37. Fougères E, Teboul JL, Richard C, et al. Hemodynamic impact of a positive end-expiratory pressure setting in acute respiratory distress syndrome: importance of the volume status. Crit Care Med 2010; 38:802.
  38. Brower RG, Morris A, MacIntyre N, et al. Effects of recruitment maneuvers in patients with acute lung injury and acute respiratory distress syndrome ventilated with high positive end-expiratory pressure. Crit Care Med 2003; 31:2592.
  39. Halter JM, Steinberg JM, Schiller HJ, et al. Positive end-expiratory pressure after a recruitment maneuver prevents both alveolar collapse and recruitment/derecruitment. Am J Respir Crit Care Med 2003; 167:1620.
  40. Lim CM, Jung H, Koh Y, et al. Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy, etiological category of diffuse lung injury, and body position of the patient. Crit Care Med 2003; 31:411.
  41. Fan E, Wilcox ME, Brower RG, et al. Recruitment maneuvers for acute lung injury: a systematic review. Am J Respir Crit Care Med 2008; 178:1156.
  42. Hodgson C, Keating JL, Holland AE, et al. Recruitment manoeuvres for adults with acute lung injury receiving mechanical ventilation. Cochrane Database Syst Rev 2009; :CD006667.
  43. Richard JC, Maggiore SM, Jonson B, et al. Influence of tidal volume on alveolar recruitment. Respective role of PEEP and a recruitment maneuver. Am J Respir Crit Care Med 2001; 163:1609.
  44. Arnal JM, Paquet J, Wysocki M, et al. Optimal duration of a sustained inflation recruitment maneuver in ARDS patients. Intensive Care Med 2011; 37:1588.
  45. Crotti S, Mascheroni D, Caironi P, et al. Recruitment and derecruitment during acute respiratory failure: a clinical study. Am J Respir Crit Care Med 2001; 164:131.
  46. Bugedo G, Bruhn A, Hernández G, et al. Lung computed tomography during a lung recruitment maneuver in patients with acute lung injury. Intensive Care Med 2003; 29:218.
  47. Foti G, Cereda M, Sparacino ME, et al. Effects of periodic lung recruitment maneuvers on gas exchange and respiratory mechanics in mechanically ventilated acute respiratory distress syndrome (ARDS) patients. Intensive Care Med 2000; 26:501.
  48. Jonson B, Richard JC, Straus C, et al. Pressure-volume curves and compliance in acute lung injury: evidence of recruitment above the lower inflection point. Am J Respir Crit Care Med 1999; 159:1172.
  49. Maggiore SM, Lellouche F, Pigeot J, et al. Prevention of endotracheal suctioning-induced alveolar derecruitment in acute lung injury. Am J Respir Crit Care Med 2003; 167:1215.
  50. Pelosi P, Cadringher P, Bottino N, et al. Sigh in acute respiratory distress syndrome. Am J Respir Crit Care Med 1999; 159:872.
  51. Pelosi P, Bottino N, Chiumello D, et al. Sigh in supine and prone position during acute respiratory distress syndrome. Am J Respir Crit Care Med 2003; 167:521.
  52. Ranieri VM, Brienza N, Santostasi S, et al. Impairment of lung and chest wall mechanics in patients with acute respiratory distress syndrome: role of abdominal distension. Am J Respir Crit Care Med 1997; 156:1082.
  53. Puybasset L, Gusman P, Muller JC, et al. Regional distribution of gas and tissue in acute respiratory distress syndrome. III. Consequences for the effects of positive end-expiratory pressure. CT Scan ARDS Study Group. Adult Respiratory Distress Syndrome. Intensive Care Med 2000; 26:1215.
  54. Zhan Q, Sun B, Liang L, et al. Early use of noninvasive positive pressure ventilation for acute lung injury: a multicenter randomized controlled trial. Crit Care Med 2012; 40:455.
  55. Marcy TW, Marini JJ. Inverse ratio ventilation in ARDS. Rationale and implementation. Chest 1991; 100:494.
  56. Marcy TW. Inverse ratio ventilation. In: Principles and Practice of Mechanical Ventilation, Tobin MJ (Ed), McGraw-Hill Inc, New York 1994. p.319.
  57. Armstrong BW Jr, MacIntyre NR. Pressure-controlled, inverse ratio ventilation that avoids air trapping in the adult respiratory distress syndrome. Crit Care Med 1995; 23:279.
  58. Mercat A, Titiriga M, Anguel N, et al. Inverse ratio ventilation (I/E = 2/1) in acute respiratory distress syndrome: a six-hour controlled study. Am J Respir Crit Care Med 1997; 155:1637.
  59. Ward NS, Lin DY, Nelson DL, et al. Successful determination of lower inflection point and maximal compliance in a population of patients with acute respiratory distress syndrome. Crit Care Med 2002; 30:963.
  60. Talmor D, Sarge T, Malhotra A, et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med 2008; 359:2095.
  61. Bernard GR. PEEP guided by esophageal pressure--any added value? N Engl J Med 2008; 359:2166.
  62. Muscedere JG, Mullen JB, Gan K, Slutsky AS. Tidal ventilation at low airway pressures can augment lung injury. Am J Respir Crit Care Med 1994; 149:1327.
  63. Mancebo J. PEEP, ARDS, and alveolar recruitment. Intensive Care Med 1992; 18:383.
  64. Dreyfuss D, Saumon G. Should the lung be rested or recruited? The Charybdis and Scylla of ventilator management. Am J Respir Crit Care Med 1994; 149:1066.
  65. Suter PM, Fairley B, Isenberg MD. Optimum end-expiratory airway pressure in patients with acute pulmonary failure. N Engl J Med 1975; 292:284.
  66. Dambrosio M, Roupie E, Mollet JJ, et al. Effects of positive end-expiratory pressure and different tidal volumes on alveolar recruitment and hyperinflation. Anesthesiology 1997; 87:495.
  67. Decailliot F, Demoule A, Maggiore SM, et al. Pressure-volume curves with and without muscle paralysis in acute respiratory distress syndrome. Intensive Care Med 2006; 32:1322.
  68. Gattinoni L, D'Andrea L, Pelosi P, et al. Regional effects and mechanism of positive end-expiratory pressure in early adult respiratory distress syndrome. JAMA 1993; 269:2122.
  69. Maggiore SM, Jonson B, Richard JC, et al. Alveolar derecruitment at decremental positive end-expiratory pressure levels in acute lung injury: comparison with the lower inflection point, oxygenation, and compliance. Am J Respir Crit Care Med 2001; 164:795.
  70. Mergoni M, Martelli A, Volpi A, et al. Impact of positive end-expiratory pressure on chest wall and lung pressure-volume curve in acute respiratory failure. Am J Respir Crit Care Med 1997; 156:846.
  71. O'Keefe GE, Gentilello LM, Erford S, Maier RV. Imprecision in lower "inflection point" estimation from static pressure-volume curves in patients at risk for acute respiratory distress syndrome. J Trauma 1998; 44:1064.
  72. Grasso S, Stripoli T, De Michele M, et al. ARDSnet ventilatory protocol and alveolar hyperinflation: role of positive end-expiratory pressure. Am J Respir Crit Care Med 2007; 176:761.
  73. Lu Q, Vieira SR, Richecoeur J, et al. A simple automated method for measuring pressure-volume curves during mechanical ventilation. Am J Respir Crit Care Med 1999; 159:275.
  74. Albert RK. Least PEEP: primum non nocere. Chest 1985; 87:2.
  75. Bouhemad B, Brisson H, Le-Guen M, et al. Bedside ultrasound assessment of positive end-expiratory pressure-induced lung recruitment. Am J Respir Crit Care Med 2011; 183:341.
  76. Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 2010; 363:1107.
  77. Alhazzani W, Alshahrani M, Jaeschke R, et al. Neuromuscular blocking agents in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials. Crit Care 2013; 17:R43.
  78. Steingrub JS, Lagu T, Rothberg MB, et al. Treatment with neuromuscular blocking agents and the risk of in-hospital mortality among mechanically ventilated patients with severe sepsis. Crit Care Med 2014; 42:90.
  79. Yoshida T, Torsani V, Gomes S, et al. Spontaneous effort causes occult pendelluft during mechanical ventilation. Am J Respir Crit Care Med 2013; 188:1420.
  80. Goddard SL, Fan E. "Only few find the way, some don't recognize it when they do …"--can we "observe" causality? Crit Care Med 2014; 42:208.