Partial Ventilatory Support Modalities in Acute Lung Injury and Acute Respiratory Distress Syndrome—A Systematic Review

Purpose The efficacy of partial ventilatory support modes that allow spontaneous breathing in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) is unclear. The objective of this scoping review was to assess the effects of partial ventilatory support on mortality, duration of mechanical ventilation, and both hospital and intensive care unit (ICU) lengths of stay (LOS) for patients with ALI and ARDS; the secondary objective was to describe physiologic effects on hemodynamics, respiratory system and other organ function. Methods MEDLINE (1966–2009), Cochrane, and EmBase (1980–2009) databases were searched using common ventilator modes as keywords and reference lists from retrieved manuscripts hand searched for additional studies. Two researchers independently reviewed and graded the studies using a modified Oxford Centre for Evidence-Based Medicine grading system. Studies in adult ALI/ARDS patients were included for primary objectives and pre-clinical studies for supporting evidence. Results Two randomized controlled trials (RCTs) were identified, in addition to six prospective cohort studies, one retrospective cohort study, one case control study, 41 clinical physiologic studies and 28 pre-clinical studies. No study was powered to assess mortality, one RCT showed shorter ICU length of stay, and the other demonstrated more ventilator free days. Beneficial effects of preserved spontaneous breathing were mainly physiological effects demonstrated as improvement of gas exchange, hemodynamics and non-pulmonary organ perfusion and function. Conclusions The use of partial ventilatory support modalities is often feasible in patients with ALI/ARDS, and may be associated with short-term physiological benefits without appreciable impact on clinically important outcomes.

[1]  R. Branson,et al.  Airway Pressure Release Ventilation , 1993 .

[2]  Unloadiing of the work of breathing by proportional assist ventilation in a lung model. , 1997, Critical care medicine.

[3]  V. Ranieri,et al.  Patient-ventilator interaction and sleep in mechanically ventilated patients: Pressure support versus proportional assist ventilation* , 2007, Critical care medicine.

[4]  C. Putensen,et al.  Cardiorespiratory effects of spontaneous breathing in two different models of experimental lung injury: a randomized controlled trial , 2008, Critical care.

[5]  C. Heneghan,et al.  Levels of Evidence , 2006 .

[6]  C. Putensen,et al.  Effect of Interfacing between Spontaneous Breathing and Mechanical Cycles on the Ventilation‐Perfusion Distribution in Canine Lung Injury , 1994, Anesthesiology.

[7]  Paolo Pelosi,et al.  Evolution of mechanical ventilation in response to clinical research. , 2008, American journal of respiratory and critical care medicine.

[8]  Christer Sinderby,et al.  Titration and implementation of neurally adjusted ventilatory assist in critically ill patients. , 2009, Chest.

[9]  C. Alexopoulou,et al.  Sleep during proportional-assist ventilation with load-adjustable gain factors in critically ill patients , 2007, Intensive Care Medicine.

[10]  M. Younes.  Proportional assist ventilation, a new approach to ventilatory support. Theory. , 1992, The American review of respiratory disease.

[11]  V. Ranieri,et al.  Tidal Volume Lower than 6 ml/kg Enhances Lung Protection: Role of Extracorporeal Carbon Dioxide Removal , 2009, Anesthesiology.

[12]  H. Hummler,et al.  Preserved spontaneous breathing improves cardiac output during partial liquid ventilation. , 2001, American journal of respiratory and critical care medicine.

[13]  C. Putensen,et al.  Assisted breathing is better in acute respiratory failure , 2005, Current opinion in critical care.

[14]  H. Buscher,et al.  Influence of different release times on spontaneous breathing pattern during airway pressure release ventilation , 2002, Intensive Care Medicine.

[15]  C. Putensen,et al.  Effects of Spontaneous Breathing during Airway Pressure Release Ventilation on Intestinal Blood Flow in Experimental Lung Injury , 2003, Anesthesiology.

[16]  J. Kress,et al.  Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. , 2000, The New England journal of medicine.

[17]  J. Rouby,et al.  Continuous positive airway pressure (CPAP) vs. intermittent mandatory pressure release ventilation (IMPRV) in patients with acute respiratory failure , 1992, Intensive Care Medicine.

[18]  W. Sibbald,et al.  Assisted ventilation in patients with preexisting cardiopulmonary disease. The effect on systemic oxygen consumption, oxygen transport, and tissue perfusion variables. , 1985, Chest.

[19]  M. Georgieff,et al.  Pressure-time product and work of breathing during biphasic continuous positive airway pressure and assisted spontaneous breathing. , 1994, American journal of respiratory and critical care medicine.

[20]  R. Rossaint,et al.  Effects of partial ventilatory support modalities on respiratory function in severe hypoxemic lung injury* , 2006, Critical care medicine.

[21]  P. Saldiva,et al.  Volume-assured pressure support ventilation (VAPSV). A new approach for reducing muscle workload during acute respiratory failure. , 1992, Chest.

[22]  A. Anzueto,et al.  Airway pressure release ventilation versus assist-control ventilation: a comparative propensity score and international cohort study , 2010, Intensive Care Medicine.

[23]  D. Tassaux,et al.  Patient-ventilator interactions during partial ventilatory support: A preliminary study comparing the effects of adaptive support ventilation with synchronized intermittent mandatory ventilation plus inspiratory pressure support , 2002, Critical care medicine.

[24]  C. Putensen,et al.  Effects of spontaneous breathing during airway pressure release ventilation on respiratory work and muscle blood flow in experimental lung injury. , 2005, Chest.

[25]  W. Peruzzi,et al.  Airway pressure release ventilation in severe acute respiratory failure. , 1991, Chest.

[26]  K. Demirağ,et al.  Comparison of Oxygen Cost of Breathing between Pressure-Support Ventilation and Airway Pressure Release Ventilation , 2005, Anaesthesia and intensive care.

[27]  G. Guyatt,et al.  Grading quality of evidence and strength of recommendations , 2004, BMJ : British Medical Journal.

[28]  D. Roberts,et al.  Proportional assist ventilation. Results of an initial clinical trial. , 1992, The American review of respiratory disease.

[29]  D. Roberts,et al.  Response of ventilator-dependent patients to different levels of proportional assist. , 1996, Journal of applied physiology.

[30]  M. Plataki,et al.  Proportional assist ventilation with load-adjustable gain factors in critically ill patients: comparison with pressure support , 2008, Intensive Care Medicine.

[31]  J. Rouby,et al.  A255 INTERMITTENT MANDATORY PRESSURE RELEASE VENTILATION (IMPRV) IN PATIENTS WITH ACUTE RESPIRATORY FAILURE , 1990 .

[32]  S. Gottfried,et al.  Proportional assist ventilation in acute respiratory failure: effects on breathing pattern and inspiratory effort. , 1996, American journal of respiratory and critical care medicine.

[33]  S. Jaber,et al.  Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. , 2008, JAMA.

[34]  C. Roussos,et al.  Pressure support ventilation in adult respiratory distress syndrome: short-term effects of a servocontrolled mode. , 1997, Journal of critical care.

[35]  R. Rossaint,et al.  Pressure support compared with controlled mechanical ventilation in experimental lung injury. , 2002, Anesthesia and analgesia.

[36]  C. Putensen,et al.  Spontaneous breathing affects the spatial ventilation and perfusion distribution during mechanical ventilatory support* , 2005, Critical care medicine.

[37]  J. Luce,et al.  Intermittent mandatory ventilation. , 1981, Chest.

[38]  C. Putensen,et al.  Spontaneous breathing during airway pressure release ventilation in experimental lung injury: effects on hepatic blood flow , 2008, Intensive Care Medicine.

[39]  G. Hedenstierna,et al.  Ventilatory Support by Continuous Positive Airway Pressure Breathing Improves Gas Exchange as Compared with Partial Ventilatory Support with Airway Pressure Release Ventilation , 2001, Anesthesia and analgesia.

[40]  Arthur S Slutsky,et al.  Non-invasive neurally adjusted ventilatory assist in rabbits with acute lung injury , 2008, Intensive Care Medicine.

[41]  C. Putensen,et al.  Ventilation-perfusion distributions during mechanical ventilation with superimposed spontaneous breathing in canine lung injury. , 1994, American journal of respiratory and critical care medicine.

[42]  L. Rose,et al.  Airway pressure release ventilation and biphasic positive airway pressure: a systematic review of definitional criteria , 2008, Intensive Care Medicine.

[43]  L. Kaplan,et al.  Airway pressure release ventilation increases cardiac performance in patients with acute lung injury/adult respiratory distress syndrome , 2001, Critical care.

[44]  D. Roberts,et al.  Response of ventilator-dependent patients to different levels of pressure support and proportional assist. , 1999, American journal of respiratory and critical care medicine.

[45]  D. Needham,et al.  Review of A Large Clinical Series: Sedation and Analgesia Usage with Airway Pressure Release and Assist-control Ventilation for Acute Lung Injury , 2008, Journal of intensive care medicine.

[46]  G. Liistro,et al.  Respiratory muscle workload in intubated, spontaneously breathing patients without COPD: pressure support vs proportional assist ventilation , 2003, Intensive Care Medicine.

[47]  C. Putensen,et al.  Clinical review: Biphasic positive airway pressure and airway pressure release ventilation , 2004, Critical care.

[48]  Diana Elbourne,et al.  Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial , 2009, The Lancet.

[49]  N. Kanj,et al.  Metabolic and Respiratory Variables during Pressure Support versus Synchronized Intermittent Mandatory Ventilation , 2008, Respiration.

[50]  G. Guyatt,et al.  Systematic review of reviews including animal studies addressing therapeutic interventions for sepsis* , 2010, Critical care medicine.

[51]  S. Powers,et al.  Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. , 2008, The New England journal of medicine.

[52]  Christer Sinderby,et al.  Improved Synchrony and Respiratory Unloading by Neurally Adjusted Ventilatory Assist (NAVA) in Lung-Injured Rabbits , 2007, Pediatric Research.

[53]  N Mutz,et al.  Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury. , 2001, American journal of respiratory and critical care medicine.

[54]  M. Younes,et al.  Proportional Assist Ventilation , 2003 .

[55]  D. Henzler.  What on earth is APRV? , 2011, Critical care.

[56]  P. Pelosi,et al.  Different modes of assisted ventilation in patients with acute respiratory failure , 2002, European Respiratory Journal.

[57]  N. MacIntyre,et al.  Demand‐flow airway pressure release ventilation as a partial ventilatory support mode: Comparison with synchronized intermittent mandatory ventilation and pressure support ventilation , 1994, Critical care medicine.

[58]  A. Rossi,et al.  Physiologic response of ventilator-dependent patients with chronic obstructive pulmonary disease to proportional assist ventilation and continuous positive airway pressure. , 1999, American journal of respiratory and critical care medicine.

[59]  P. Pelosi,et al.  Effects of Different Levels of Pressure Support Variability in Experimental Lung Injury , 2009, Anesthesiology.

[60]  C. Putensen,et al.  Effects of spontaneous breathing during airway pressure release ventilation on renal perfusion and function in patients with acute lung injury , 2002, Intensive Care Medicine.

[61]  Paolo Navalesi,et al.  Physiologic response to varying levels of pressure support and neurally adjusted ventilatory assist in patients with acute respiratory failure , 2008, Intensive Care Medicine.

[62]  J. Milic-Emili,et al.  Effect of Different Levels of Pressure Support and Proportional Assist Ventilation on Breathing Pattern, Work of Breathing and Gas Exchange in Mechanically Ventilated Hypercapnic COPD Patients with Acute Respiratory Failure , 2003, Respiration.

[63]  A. Artigas,et al.  Report of the American-European consensus conference on ARDS: Definitions, mechanisms, relevant outcomes and clinical trial coordination , 1994, Intensive Care Medicine.

[64]  C. Hörmann,et al.  Effects of spontaneous breathing with BIPAP on pulmonary gas exchange in patients with ARDS. , 1997, Acta anaesthesiologica Scandinavica. Supplementum.

[65]  J. Walter,et al.  Diaphragm and accessory respiratory muscle stimulation using intramuscular electrodes. , 1995, Archives of physical medicine and rehabilitation.

[66]  C. Putensen,et al.  Spontaneous Breathing Improves Lung Aeration in Oleic Acid–induced Lung Injury , 2003, Anesthesiology.

[67]  P. Pelosi,et al.  Assisted ventilation modes reduce the expression of lung inflammatory and fibrogenic mediators in a model of mild acute lung injury , 2010, Intensive Care Medicine.

[68]  G. Foti,et al.  Pressure support ventilation in patients with acute lung injury , 2000, Critical care medicine.

[69]  Ehab Daoud,et al.  Airway pressure release ventilation , 2007, Annals of thoracic medicine.

[70]  A. Møller,et al.  How to use evidence‐based medicine in anaesthesiology , 2001, Acta anaesthesiologica Scandinavica.

[71]  Arthur S Slutsky,et al.  Compensation for increase in respiratory workload during mechanical ventilation. Pressure-support versus proportional-assist ventilation. , 2000, American journal of respiratory and critical care medicine.

[72]  M. Sydow,et al.  Sedation for the critically ill , 1999, Intensive Care Medicine.

[73]  E. Kondili,et al.  Short-term Cardiorespiratory Effects of Proportional Assist and Pressure-support Ventilation in Patients with Acute Lung Injury/Acute Respiratory Distress Syndrome , 2006, Anesthesiology.

[74]  P. Pelosi,et al.  Noisy pressure support ventilation: A pilot study on a new assisted ventilation mode in experimental lung injury* , 2008, Critical care medicine.

[75]  R. Burns,et al.  Preliminary experience with airway pressure release ventilation in a trauma/surgical intensive care unit. , 2005, The Journal of trauma.

[76]  J. Modell,et al.  Intermittent Mandatory Ventilation: An Evaluation , 1974 .

[77]  C. Alexopoulou,et al.  Respiratory load compensation during mechanical ventilation—proportional assist ventilation with load-adjustable gain factors versus pressure support , 2006, Intensive Care Medicine.

[78]  J. Kienast,et al.  Volume-controlled versus biphasic positive airway pressure ventilation in leukopenic patients with severe respiratory failure. , 1996, Critical care medicine.

[79]  马建新,et al.  用FEV6．0代替FVC诊断气道阻塞和肺功能受限[英]／Swanney MP…∥Am J Respir Crit Care Med． , 2002 .

[80]  R. Rossaint,et al.  Ventilation with biphasic positive airway pressure in experimental lung injury , 2004, Intensive Care Medicine.

[81]  L. Cinotti,et al.  Changes in the distribution of ventilation and perfusion associated with separation from mechanical ventilation in patients with obstructive pulmonary disease. , 1991, Anesthesiology.

[82]  I. Jousela,et al.  Combined effects of prone positioning and airway pressure release ventilation on gas exchange in patients with acute lung injury , 2003, Acta anaesthesiologica Scandinavica.

[83]  P. Valta,et al.  Airway pressure release ventilation as a primary ventilatory mode in acute respiratory distress syndrome , 2004, Acta anaesthesiologica Scandinavica.

[84]  M. Lamy,et al.  The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. , 1994, American journal of respiratory and critical care medicine.

[85]  R. Kirby,et al.  Airway pressure release ventilation during acute lung injury: A prospective multicenter trial , 1991, Critical care medicine.

[86]  P. Pelosi,et al.  Pressure Support Ventilation and Biphasic Positive Airway Pressure Improve Oxygenation by Redistribution of Pulmonary Blood Flow , 2009, Anesthesia and analgesia.

[87]  D. Schoenfeld,et al.  Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. , 2000, The New England journal of medicine.

[88]  Arthur S Slutsky,et al.  Influence of neurally adjusted ventilatory assist and positive end-expiratory pressure on breathing pattern in rabbits with acute lung injury* , 2006, Critical care medicine.

[89]  M. Mathru,et al.  Ventilator‐induced barotrauma in controlled mechanical ventilation versus intermittent mandatory ventilation , 1983, Critical care medicine.

[90]  A. Loundou,et al.  Neuromuscular blockers in early acute respiratory distress syndrome. , 2010, The New England journal of medicine.

[91]  D. Rapoport,et al.  Mechanism of relief of tachypnea during pressure support ventilation. , 1996, Chest.

[92]  Arthur S Slutsky,et al.  Neurally adjusted ventilatory assist decreases ventilator-induced lung injury and non-pulmonary organ dysfunction in rabbits with acute lung injury , 2009, Intensive Care Medicine.

[93]  Arthur S Slutsky,et al.  Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. , 2008, JAMA.

[94]  C. Putensen,et al.  Spontaneous breathing during ventilatory support improves ventilation-perfusion distributions in patients with acute respiratory distress syndrome. , 1999, American journal of respiratory and critical care medicine.