Protective ventilation of patients with acute respiratory distress syndrome

• Published in: British journal of anaesthesia : BJA Vol. 92; no. 2; pp. 261 - 270
• Main Authors: Moloney, E. D., Griffiths, M. J. D.
• Format: Journal Article
• Language: English
• Published: Oxford Elsevier Ltd 01-02-2004; Oxford University Press; Oxford Publishing Limited (England)
• Subjects: acute respiratory distress syndrome; Anesthesia; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Barotrauma - etiology; Biological and medical sciences; complications; complications, acute respiratory distress syndrome; complications, ventilator-associated lung injury; Humans; Lung Injury; mechanical; Medical sciences; Respiration, Artificial - adverse effects; Respiration, Artificial - methods; Respiratory Distress Syndrome, Adult - physiopathology; Respiratory Distress Syndrome, Adult - therapy; ventilation; ventilation, mechanical; ventilator‐associated lung injury; complications, acute respiratory distress syndrome; ventilation, mechanical; complications, ventilator-associated lung injury; complications, acute respiratory distress syndrome; complications, ventilator‐associated lung injury; ventilation, mechanical; Human; Air leak; Lung disease; Ventilator; Prognosis; acute respiratory distress syndrome; complications; Support; complications; ventilator- associated lung injury; ventilation; Respiratory disease; Toxicity; Acute; Mortality; Tidal volume; mechanical; Research; Prevention; Symptomatology; Respiratory distress; Disseminated; Hemodynamics; Mechanical ventilation; Organ
• ISSN: 0007-0912; 1471-6771
• DOI: 10.1093/bja/aeh031

The majority of patients with acute respiratory distress syndrome (ARDS) require mechanical ventilation. This support provides time for the lungs to heal, but the adverse effects of mechanical ventilation significantly influence patient outcome. Traditionally, these were ascribed to mechanical effects, such as haemodynamic compromise from decreased venous return or gross air leaks induced by large transpulmonary pressures. More recently, however, the ARDS Network study has established the clinical importance of lowering the tidal volume to limit overdistension of the lung when ventilating patients with ARDS. This study suggests that ventilator-associated lung injury (VALI) caused by overdistension of the lung contributes to the mortality of patients with ARDS. Moreover, the results from clinical and basic research have revealed more subtle types of VALI, including upregulation of the inflammatory response in the injured and overdistended lung. This not only damages the lung, but the overflow of inflammatory mediators into the systemic circulation may explain why most patients who die with ARDS succumb to multi-organ failure rather than respiratory failure. The results of these studies, the present understanding of the pathophysiology of VALI, and protective ventilatory strategies are reviewed.