Introduction
Materials and methods
Population
Basic ventilation
Recruitment manoeuvre
Prone position
Protocol
Statistical methods
Results
Population
Patient demographics | Pulmonary ARDS | Extrapulmonary ARDS |
---|---|---|
Number of patients | 12 | 4 |
Average age, years | 63 | 66 |
SAPS II | 47 | 39 |
Organ failureb | 2.5 | 1.75 |
PaO2/FiO2 ratio at time 0, mmHg | 99 | 97.5 |
Deaths, n | 5 | 2 |
Diagnosis, n | ||
Pneumonia | 9 | |
Aspiration | 3 | |
Acute pancreatitis | 4 |
Ventilatory settings
SP | PP | SP | |||||||
---|---|---|---|---|---|---|---|---|---|
Ventilatory setting | Time 0 | Time 1 (RM1) time 2 | Time 3 | Time 4 (RM2) time 5 | Time 6 (RM3) time 7 | Time 8 | |||
Vt, mL | 536 ± 105 | 522 ± 106.8 | 534 ± 102 | 532 ± 102 | 511 ± 99 | 511 ± 98.7 | 512 ± 97.8 | 512 ± 98.2 | 512 ± 98 |
RR, breaths/minute | 19 ± 4.1 | 19.5 ± 4.1 | 19.5 ± 4.3 | 19.5 ± 4.3 | 20 ± 4.4 | 20 ± 4.4 | 20 ± 4.4 | 20 ± 4.4 | 20 ± 4.4 |
V°, L/minute | 10.5 ± 2.3 | 10.2 ± 2 | 10.4 ± 2.2 | 10.4 ± 2.1 | 10.2 ± 2.2 | 10.2 ± 2.2 | 10.2 ± 2.2 | 10.3 ± 2.2 | 10.3 ± 2.2 |
External PEEP, cmH2O | 9.8 ± 2.8 | 9.8 ± 2.8 | 9.8 ± 2.8 | 9.8 ± 2.8 | 10.1 ± 2.6 | 10.1 ± 2.6 | 10.1 ± 2.6 | 10.1 ± 2.6 | 10.3 ± 2.7 |
Total PEEP, cmH2O | 10.7 ± 2.8 | 10.6 ± 2.8 | 10.8 ± 2.9 | 10.8 ± 2.7 | 10.9 ± 3 | 11.4 ± 3.3 | 10.5 ± 2.8 | 10.6 ± 2.9 | 10.8 ± 3 |
Paw, cmH2O | 31.7 ± 4.7 | 30.5 ± 6 | 30.2 ± 5.7 | 31 ± 4.9 | 29 ± 5.2 | 30.5 ± 5.2 | 29 ± 5.9 | 28 ± 5.3 | 29 ± 5.3 |
Pplat, cmH2O | 24.6 ± 5.8 | 24.5 ± 5.7 | 24 ± 5.5 | 25.3 ± 5b | 24.2 ± 4.6 | 24 ± 4.1 | 23.4 ± 4.9 | 22.7 ± 5c | 23 ± 5.1 |
Gas exchange
SP | PP | SP | |||||||
---|---|---|---|---|---|---|---|---|---|
Gas exchanges | Time 0 | Time 1 (RM1) time 2 | Time 3 | Time 4 (RM2) time 5 | Time 6 (RM3) time 7 | Time 8 | |||
pH | 7.37 ± 0.08 | 7.37 ± 0.07 | 7.40 ± 0.08b | 7.36 ± 0.08c | 7.39 ± 0.08 | 7.43 ± 0.08d | 7.40 ± 0.09 | 7.47 ± 0.08e | 7.40 ± 0.08f |
PaO2, mmHg | 75.6 ± 19 | 85.4 ± 28 | 94.5 ± 39 | 88.9 ± 24 | 117 ± 63 | 138 ± 77 | 138.6 ± 70 | 171.5 ± 84g | 129.5 ± 66h |
PaCO2, mmHg | 39 ± 7 | 39 ± 7.7 | 35 ± 7.4i | 40 ± 8.4j | 37 ± 8.4 | 35 ± 7.7k | 36.4 ± 8.4 | 31.5 ± 8.4l | 36.4 ± 7.3m |
PaO2/FiO2 ratio, mmHg | 98.3 ± 28 | 111.4 ± 41.2 | 123 ± 52.3 | 115.5 ± 36 | 151.2 ± 75.7 | 178 ± 99 | 177 ± 75 | 218.2 ± 99.5n | 165.6 ± 84.5° |
Impact of RM on gas exchange
Impact of RM on gas exchange depending on body position
Impact of the global strategy on gas exchange
Impact of RM on gas exchange depending on extrapulmonary or pulmonary ARDS
Haemodynamics
Complications
Discussion
Baseline ventilation | Best PaO2/FiO2 ratio variation (mmHg), PP + RM | |||||||||
---|---|---|---|---|---|---|---|---|---|---|
Study | ARDS type, number of patients | Vt, mL | RR, breaths/minute | PEEP, cmH2O | PaO2/FiO2 ratio, mmHg | Pplat, cmH2O | Pre-PaO2/FiO2 ratio, mmHg | Post- PaO2/FiO2 ratio, mmHg | RM type | Study design |
Pelosi et al., 2003 [43] | Early ARDS (n = 10): 6 pulmonary, 4 extrapulmonary | About 7 mL/kg 590 mL | 14 | 14 | 121 | 32 | 193 | 240 | Sigh: Three consecutive volume-limited breaths/minute with a plateau pressure of 45 cmH2O | Following period of the study: 2-hour baseline SP 1-hour sigh SP 1-hour baseline SP 2-hour baseline PP 1-hour sigh PP 1-hour baseline PP Measurements taken at end of each period |
Lim et al., 2003 [45] | Early ARDS (n = 47): 37 pulmonary, 10 extrapulmonary 19 patients from a preliminary study | About 8 mL/kg | 20 | 10 | 128 | - | 166 | 200 | Extended sigh Inflation phase: PEEP was increased by 5 cmH2O every 30 seconds with a 2 mL/kg decrease in Vt. When PEEP reached 25 cmH2O, CPAP at 30 cmH2O was used for 30 seconds. Deflation phase | Following period of the study: Patients were randomised into two arms: (1) RM + PEEP at 15 cmH2O (n = 20) or (2) PEEP alone at 15 cmH2O (n = 8). A third arm of patients from a preliminary study were analysed: RM only (n = 19). PP was used only if PaO2/FiO2 ratio was < 100 (n = 14). The protocol started after 2-hour PP. Data were recorded before and after RM + PEEP (or PEEP only or RM only) at 15, 30, 45 and 60 minutes after the protocol. |
Oczenski et al., 2005 [44] | Early ARDS (n = 15): all extrapulmonary | About 6 mL/kg 460 to 490 mL | 18 | 15 | 130 | 29 | 176 | 322 | CPAP: 50 cmH2O for 30 seconds | Following period of the study: After 6-hour PP period, RM was performed. Data were recorded in SP after 6 hours PP and 3, 30 and 180 minutes after RM in SP. |
Rival et al., 2011 (present study) | Early ARDS (n = 16): 12 pulmonary, 4 extrapulmonary | - 540 mL | 19 | 10 | 98 | 25 | 177 | 218 | Extended sigh inflation phase: Pressure levels 30, 35, 40 and 45 cmH2O every 30 seconds were used. At 45 cmH2O, a 30-second end inspiratory pause was performed. Deflation phase | Following period of the study: 6-hour SP with RM at beginning of SP. Six-hour PP with two RM after 1 hour and 6-hour PP. Measurements taken at beginning of, before and after each RM, and also at end of each ventilation period and 1 hour after end of protocol. |
Oxygenation efficacy
Recruitment manoeuvre strategy
Respiratory mechanics
Complications
Methodological considerations and limitations
Conclusions
Key messages
-
RM can be used in SP or PP to improve oxygenation.
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A pressure control mode was as efficient as other RMs.
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A probable combined effect on oxygenation exists between PP and RM.
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The combination of PP and RM may be assessed several times, preferably when the patient has been in PP for a few hours.
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No significant side effects were encountered in our study.