Acute respiratory distress syndrome mechanical ventilation therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Brian Shaller, M.D. [2]

Overview

Most patients with ARDS will require endotracheal intubation and mechanical ventilation at some point during the course of their illness and recovery. A mechanical ventilation strategy using lower tidal volumes of 6 mL/kg predicted body weight and higher levels of positive end-expiratory pressure (PEEP) has been shown to be most effective at improving oxygenation and minimizing volutrauma (injury to stiff lungs resulting from overdistention).

As an overview, a quasi-experimental, before-after trial[1] found reduced mortality associated with the following strategy quoted from Journal Watch[2]:

  • use tidal volumes <6.5 mL/kg,
  • use a PEEP of 5–24 cm H20 within a plateau pressure <30 cm H20,
  • decrease FiO2 as permitted to achieve saturation of 88%–95%,
  • and elevate the head of the bed. Hypercapnia with a pH >7.25 is permissible.
  • Use a higher flow rate (up to 100 L/min) for obstructive airway disease when necessary to achieve a satisfactory I:E ratio

Mechanical ventilation

  • Lower tidal volume ventilation (6 mL/kg predicted body weight) is associated with reduced mortality and a greater number of ventilator-free days[3]
  • PBW (men) = 50 + 2.3 (height in inches – 60)
  • PBW (women) = 45.5 + 2.3 (height in inches – 60)
  • Higher positive end-expiratory pressure (PEEP) combined with lower tidal volume ventilation is associated with decreased mortality in patients with moderate or severe ARDS (PaO2/FIO2 ≤ 200)[4]
  • Prone positioning for at least 16 consecutive hours each day is associated with improved 28-day and 90-day survival in patients with ARDS and a PaO2/FIO2 ratio < 150 on an FIO2 ≥ 60% and PEEP ≥ 5 mmHg
  • Cisatracurium, when started within the first 48 hours of ARDS diagnosis and continued for 48 hours, has been associated with improved 90-day survival, a greater number of ventilator-free days, and a decreased incidence of volutrauma[5]

ARDS Network Mechanical Ventilation Protocol

In 1994 the National Institutes of Health (NIH) and National Heart, Lung, and Blood Institute (NHLBI) founded the ARDS Clinical Trial Network (often abbreviated as ARDSnet) – a consortium of over 40 hospitals that conduct clinical research trials aimed at improving care for patients with ARDS. In order to simplify the mechanical ventilation of patients with ARDS, the NIH-NHLBI ARDS Network has compiled a Mechanical Ventilation Protocol Summary[6] that outlines the mechanical ventilation strategies associated with better outcomes in an easy-to-use format for ICU health care providers.

Non-Invasive Positive Pressure Ventilation

Many patients who develop ARDS will receive a trial of non-invasive positive pressure ventilation (NIPPV) before intubation and mechanical ventilation become necessary to maintain adequate oxygenation, or before the degree of clinical deterioration precludes the use of NIPPV and necessitates endotracheal intubation for airway protection. Several studies have examined the utility of NIPPV in the management of ARDS:

  • NIPPV observational data from cohort studies: Early application of NIPPV appears to reduce the rate of intubation and mechanical ventilation in patients with mild-to-moderate ARDS (PaO2/FIO2 ratio 150 to 200)[7][8]
  • NIPPV versus high-flow nasal cannula (HFNC) or supplemental oxygen via face mask: 310 patients with ARDS and a PaO2/FIO2 ratio ≤ 300 were randomized to either NIPPV, high-flow nasal cannula, or supplemental oxygen via face mask[9]
  • At 28 days, no differences in were seen in rates of intubation and mechanical ventilation between the three groups
  • At 90 days, there were significantly more ICU-free days and significantly fewer mortalities in the high-flow nasal cannula group as compared to the other two groups
  • NIPPV via face mask versus NIPPV via helmet: 83 patients with ARDS were randomized to either NIPPV via face mark or NIPPV via helmet[10]
  • At 28 days, there was a significantly lower rate of intubation and significantly more ventilator-free days in the helmet group
  • At 90 days, there were significantly fewer mortalities in the helmet group
  • Study was terminated early due to the significantly higher mortality rate seen in the face mask group

Alternative Mechanical Ventilation Strategies

Several specialized modes of mechanical ventilation have been tested in ARDS, however, none has been proven to carry a morbidity or mortality benefit and should only be considered if oxygenation does not improve with a judicious trial of the first-line mechanical ventilation strategies as outlined by the ARDS Network.[11]

Recruitment Maneuvers

A recruitment maneuver is the application of very high (up to 40 cm H2O) positive airway pressure to open collapsed alveoli, thereby reducing shunting, decreasing V/Q mismatching, and improving gas exchange. The decision to apply recruitment maneuvers must take into account various factors including the extent of lung injury (due to the risk of causing volutrauma through overdistention of stiff and inflamed lungs) and patient hemodynamics (due to the risk of further worsening hypotension by impeding venous return to the right heart). Recruitment maneuvers have not been standardized and there are insufficient data to support or discourage their use in ARDS.

Extracorporeal Membrane Oxygenation (ECMO)

There is growing evidence to support the use of extracorporeal membrane oxygenation (ECMO) for severe ARDS that fails to improve despite judicious application of the ARDS Network low tidal volume/high PEEP ventilation strategy.[16][17] ECMO facilitates gas exchange in circumstances where adequate oxygenation and ventilation cannot be achieved through the lungs themselves. There are two main forms of ECMO, both of which have been used successfully in the treatment of severe ARDS:

  • Veno-arterial (VA)-ECMO: Venous blood is removed through an outflow cannula placed in a large vein (usually the right femoral vein or inferior vena cava) and passed through an oxygenator where gas exchange occurs (CO2 is removed and O2 is introduced) before being returned to the body through an inflow cannula placed in a large artery (usually the right femoral artery or right carotid artery)

The use of ECMO in the treatment of ARDS is an ongoing area of research, and referral to a medical center with ample experience in the use of ECMO for ARDS should be considered for patients with ARDS who are failing traditional management strategies and may be candidates for ECMO. The use of ECMO requires systemic anticoagulation (usually with heparin) and is associated with the risk of major hemorrhage as well as thrombosis. Additionally, the use of VA-ECMO may result in ischemic injury to the limb distal to the site of the inflow cannula (although rates of limb ischemia have been mitigated by the addition of a reperfusion cannula that takes blood from the inflow cannula and delivers it distally to the otherwise-affected limb).

References

  1. Fuller BM, Ferguson IT, Mohr NM, Drewry AM, Palmer C, Wessman BT; et al. (2017). "A Quasi-Experimental, Before-After Trial Examining the Impact of an Emergency Department Mechanical Ventilator Protocol on Clinical Outcomes and Lung-Protective Ventilation in Acute Respiratory Distress Syndrome". Crit Care Med. doi:10.1097/CCM.0000000000002268. PMID 28157140.
  2. "Lung Protective Strategy for Acute Respiratory Distress Syndrome Saves Lives". NEJM Journal Watch. 2017. Retrieved 2017-03-07.
  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. 342 (18): 1301–8. 2000. doi:10.1056/NEJM200005043421801. PMID 10793162.
  4. Briel M, Meade M, Mercat A, Brower RG, Talmor D, Walter SD; et al. (2010). "Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis". JAMA. 303 (9): 865–73. doi:10.1001/jama.2010.218. PMID 20197533.
  5. Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A; et al. (2010). "Neuromuscular blockers in early acute respiratory distress syndrome". N Engl J Med. 363 (12): 1107–16. doi:10.1056/NEJMoa1005372. PMID 20843245. Review in: Ann Intern Med. 2011 Jan 18;154(2):JC1-3
  6. NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary. (2008). http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf Accessed on June 28, 2016
  7. Antonelli M, Conti G, Esquinas A, Montini L, Maggiore SM, Bello G; et al. (2007). "A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome". Crit Care Med. 35 (1): 18–25. doi:10.1097/01.CCM.0000251821.44259.F3. PMID 17133177.
  8. Thille AW, Contou D, Fragnoli C, Córdoba-Izquierdo A, Boissier F, Brun-Buisson C (2013). "Non-invasive ventilation for acute hypoxemic respiratory failure: intubation rate and risk factors". Crit Care. 17 (6): R269. doi:10.1186/cc13103. PMC 4057073. PMID 24215648.
  9. Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S; et al. (2015). "High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure". N Engl J Med. 372 (23): 2185–96. doi:10.1056/NEJMoa1503326. PMID 25981908.
  10. Patel BK, Wolfe KS, Pohlman AS, Hall JB, Kress JP (2016). "Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial". JAMA. 315 (22): 2435–41. doi:10.1001/jama.2016.6338. PMID 27179847.
  11. NIH-NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary. "http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf"
  12. Derdak S, Mehta S, Stewart TE, Smith T, Rogers M, Buchman TG; et al. (2002). "High-frequency oscillatory ventilation for acute respiratory distress syndrome in adults: a randomized, controlled trial". Am J Respir Crit Care Med. 166 (6): 801–8. doi:10.1164/rccm.2108052. PMID 12231488.
  13. Ferguson ND, Cook DJ, Guyatt GH, Mehta S, Hand L, Austin P; et al. (2013). "High-frequency oscillation in early acute respiratory distress syndrome". N Engl J Med. 368 (9): 795–805. doi:10.1056/NEJMoa1215554. PMID 23339639.
  14. Daoud EG (2007). "Airway pressure release ventilation". Ann Thorac Med. 2 (4): 176–9. doi:10.4103/1817-1737.36556. PMC 2732103. PMID 19727373.
  15. Daoud EG, Farag HL, Chatburn RL (2012). "Airway pressure release ventilation: what do we know?". Respir Care. 57 (2): 282–92. doi:10.4187/respcare.01238. PMID 21762559.
  16. Gattinoni L, Pesenti A, Mascheroni D, Marcolin R, Fumagalli R, Rossi F; et al. (1986). "Low-frequency positive-pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure". JAMA. 256 (7): 881–6. PMID 3090285.
  17. Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM; et al. (2009). "Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial". Lancet. 374 (9698): 1351–63. doi:10.1016/S0140-6736(09)61069-2. PMID 19762075.

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