Pulmonology
Acute respiratory distress syndrome (ARDS) & lung-protective ventilation strategies
Acute Respiratory Distress Syndrome (ARDS) is a severe form of respiratory failure characterized by widespread lung inflammation, alveolar damage, and impaired gas exchange. It remains a major challenge in intensive care, with high morbidity and mortality rates despite advances in ventilatory support and critical care management.
To optimize oxygenation and ventilation while preventing further lung injury, a structured approach to lung-protective ventilation is essential. This section covers:
- Current ARDS guidelines, including updated definitions, phenotyping, and respiratory support strategies.
- Lung- and diaphragm-protective ventilation, balancing lung-protective measures with adequate respiratory muscle activity.
- PEEP titration, recruitment maneuvers, and strategies to optimize alveolar recruitment while minimizing overdistention.
- The role of oesophageal balloon manometry, a tool for personalizing ventilator settings by estimating pleural pressure and assessing inspiratory effort.
By integrating evidence-based guidelines and emerging monitoring techniques, clinicians can improve ARDS management, enhance lung protection, and reduce ventilator-associated complications.
Acute respiratory distress syndrome (ARDS)
Acute respiratory distress syndrome
ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies
Giacomo Grasselli et al., Intensive Care Medicine (2023)
What’s inside
This article presents the updated 2023 clinical practice guidelines from the European Society of Intensive Care Medicine (ESICM) on acute respiratory distress syndrome (ARDS). It addresses 21 questions and provides recommendations across various domains, including definition, phenotyping, and respiratory support strategies such as high-flow nasal cannula oxygen, non-invasive ventilation, tidal volume setting, positive end-expiratory pressure, recruitment maneuvers, prone positioning, neuromuscular blockade, and extracorporeal life support.
Why it’s relevant
ARDS accounts for approximately 10% of intensive care unit admissions and has a mortality rate of up to 45% in severe cases. The COVID-19 pandemic has further highlighted the need for updated guidelines to improve patient outcomes. These guidelines provide evidence-based recommendations to enhance the management of ARDS in clinical practice.
Key focus
- Updated definitions and phenotyping of ARDS to improve diagnosis and treatment.
- Recommendations on various respiratory support strategies, including:
- High-flow nasal cannula oxygen
- Non-invasive ventilation
- Tidal volume settings
- Positive end-expiratory pressure and recruitment maneuvers
- Prone positioning
- Neuromuscular blockade
- Extracorporeal life support
Takeaway
The 2023 ESICM guidelines offer comprehensive, evidence-based recommendations for the management of ARDS, aiming to standardize care and improve patient outcomes in intensive care settings.
Lung and diaphragm-protective ventilation
Lung-protective ventilation
Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort
Ewan C. Goligher et al., Intensive Care Medicine (2020)
What’s inside
This article explores lung and diaphragm-protective mechanical ventilation strategies, focusing on balancing respiratory support and patient effort. It provides guidance on ventilator settings, monitoring, patient-ventilator interaction, and sedation to prevent lung injury and diaphragm dysfunction.
Why it’s relevant
Mechanical ventilation can cause complications like ventilator-induced lung injury and diaphragm weakness. A lung and diaphragm-protective approach aims to minimize these risks, improving patient outcomes and reducing ventilation duration.
Key focus
- Limiting tidal volumes and pressures to protect the lungs.
- Maintaining respiratory muscle activity to prevent diaphragm atrophy.
- Monitoring respiratory effort and ensuring patient-ventilator synchrony.
- Sedation strategies that avoid suppressing respiratory drive.
- Potential adjunctive therapies to support lung and diaphragm protection.
Takeaway
Combining lung and diaphragm-protective strategies tailored to the individual patient can prevent complications and enhance recovery during mechanical ventilation.
PEEP titration
Positive end-expiratory pressure (PEEP) in ARDS
Setting Positive End-Expiratory Pressure in Acute Respiratory Distress Syndrome
Dean R Hess, Respiratory Care (2015)
What’s inside
This article provides a comprehensive review of recruitment maneuvers and positive end-expiratory pressure (PEEP) titration in mechanical ventilation, particularly for patients with acute respiratory distress syndrome (ARDS). It discusses the physiological principles, potential benefits, and risks associated with these strategies, and offers practical guidance on their application in clinical practice.
Why it’s relevant
Effective management of ARDS requires strategies that enhance alveolar recruitment while minimizing ventilator-induced lung injury. Understanding the appropriate use of recruitment maneuvers and PEEP titration is essential for optimizing oxygenation and improving patient outcomes in critical care settings.
Key focus
- Overview of the physiological basis for recruitment maneuvers and PEEP in ARDS management.
- Discussion of various techniques for performing recruitment maneuvers, including sustained inflations and stepwise approaches.
- Examination of methods for PEEP titration to balance alveolar recruitment against the risk of overdistention.
- Analysis of clinical evidence regarding the efficacy and safety of recruitment maneuvers and PEEP titration.
- Recommendations for integrating these strategies into a lung-protective ventilation approach.
Takeaway
Recruitment maneuvers and careful PEEP titration can be valuable components of mechanical ventilation in ARDS patients. However, their application should be individualized, considering the patient's lung mechanics and potential for recruitment, to maximize benefits and minimize risks.
The oesophageal balloon
The oesophageal balloon
The oesophageal balloon for respiratory monitoring in ventilated patients: updated clinical review and practical aspects
Annemijn H. Jonkman et al., European Respiratory Review (2023)
What’s inside
This article provides an updated clinical review on the use of oesophageal balloon manometry for respiratory monitoring in mechanically ventilated patients. It discusses the physiological principles, practical implementation, and potential benefits of measuring oesophageal pressure (Poes) to estimate pleural pressure, assess respiratory mechanics, and guide individualized ventilator settings.
Why it’s relevant
Personalizing mechanical ventilation is crucial to protect both the lungs and diaphragm in critically ill patients. Oesophageal manometry offers a method to monitor respiratory physiology more accurately, potentially improving patient outcomes by optimizing ventilatory support and preventing ventilator-induced injuries.
Key focus
- Explanation of physiological concepts assessed using Poes measurements during spontaneous breathing and mechanical ventilation.
- Practical guidance for implementing oesophageal manometry at the bedside.
- Discussion on setting positive end-expiratory pressure (PEEP) in controlled ventilation.
- Assessment of inspiratory effort during assisted ventilation modes.
Takeaway
Oesophageal balloon manometry is a valuable tool for enhancing respiratory monitoring in ventilated patients. While further clinical data are needed to confirm its benefits and determine optimal targets, its application can contribute to more individualized and protective mechanical ventilation strategies.