Medscape Critical Care Should Patients With ARDS Be Allowed to - TopicsExpress

Medscape Critical Care Should Patients With ARDS Be Allowed to Initiate Breaths? Aaron B. Holley, MD January 15, 2014 medscape/viewarticle/819005 Personal Alert Add Acute Respiratory Distress Syndrome (ARDS) to My Topic Alert Drug & Reference Information Acute Respiratory Distress Syndrome Barotrauma and Mechanical Ventilation Pediatric Acute Respiratory Distress Syndrome Introduction Conventional wisdom says that spontaneous breathing during mechanical ventilation is beneficial. Negative pleural pressures open alveoli without subjecting them to artificial positive pressure. Only through contraction and depression of the diaphragm can the dependent portions of the lung be used for ventilation in the intubated patient. So why the recent negative press?[1,2] Its all about the transpulmonary pressure (PL), which equals plateau pressure (PPL) minus pleural pressure (PP). Though much lip service is paid to setting positive end-expiratory pressure and monitoring PPL, theyre simply surrogates for the PL, the pressure that really matters. If it falls below zero, youre likely to derecruit, worsen compliance, and cause atelectrauma. If it increases too much, youll risk barotrauma.[3] What does this have to do with spontaneous breathing? Vigorous inspiratory efforts can significantly reduce PP, especially when breathing is asynchronous with the ventilator. Negative PP will increase PL, potentially to dangerous levels. To make matters worse, most intensive care units dont routinely measure PP, so in most cases we cant calculate the PL. Conclusion Theres no doubt that spontaneous breathing is important for the intubated patient, especially when ventilator support is prolonged. Caution is warranted early on, though, especially when patients are intubated for acute lung injury or acute respiratory distress syndrome (ARDS). These patients have particularly noncompliant lungs and are at elevated risk for ventilator-induced lung injury. If youre going to let them initiate spontaneous breaths, make sure theyre synchronous with the ventilator and consider using an esophageal catheter to calculate PL.[4] Neuromuscular blockade may be beneficial in the setting of moderate-to-severe ARDS.[5]

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