The following case describes the favorable application of airway pressure release ventilation (APRV) in a patient with pulmonary hypertension who developed respiratory failure and abdominal compartment syndrome after ...The following case describes the favorable application of airway pressure release ventilation (APRV) in a patient with pulmonary hypertension who developed respiratory failure and abdominal compartment syndrome after abdominal closure from an incarcerated umbilical hernia. A 66-year-old male with past medical history of restrictive lung disease, obstructive sleep apnea and pulmonary hypertension, presented to the operating room for an incarcerated inguinal hernia. After abdominal closure, he gradually developed decreased oxygen saturation and hypotension. APRV was initiated during post operative day 2 after inability to maintain adequate oxygen saturation with resultant hypotension on pressure control ventilation with varying degrees of positive end expiratory pressure and 100% inspired oxygen concentration. The initial set high pressure on APRV was 35 mm Hg. Yet, in lieu of decreasing lung compliance, it peaked at 50 mm Hg. Eventually, inhaled Nitric Oxide was initiated post operative day 3 due to increasing pulmonary arterial pressures. A bedside laparotomy was eventually performed when bladder pressures peaked to 25 mm Hg. APRV gradually and temporally improved the oxygen saturation and decreased the pulmonary arterial pressures with subsequent increase in systemic blood pressures. APRV promoted alveolar recruitment and decreased the shunting associated with abdominal compartment syndrome. Better oxygen saturations lead to increases in blood pressure by decreasing the effects of hypoxic pulmonary vasoconstriction on the right ventricle (RV). In patients with decreasing lung compliance and pulmonary comorbidities, APRV appears safe and allows for improve oxygenation, after failure with conventional modes of ventilation.展开更多
Mechanical ventilation(MV)is an essential life support method for patients with acute respiratory distress syn-drome(ARDS),which is one of the most common critical illnesses with high mortality in the intensive care u...Mechanical ventilation(MV)is an essential life support method for patients with acute respiratory distress syn-drome(ARDS),which is one of the most common critical illnesses with high mortality in the intensive care unit(ICU).A lung-protective ventilation strategy based on low tidal volume(LTV)has been recommended since a few years;however,as this did not result in a significant decrease of ARDS-related mortality,a more optimal venti-lation mode was required.Airway pressure release ventilation(APRV)is an old method defined as a continuous positive airway pressure(CPAP)with a brief intermittent release phase based on the open lung concept;it also perfectly fits the ARDS treatment principle.Despite this,APRV has not been widely used in the past,rather only as a rescue measure for ARDS patients who are difficult to oxygenate.Over recent years,with an increased under-standing of the pathophysiology of ARDS,APRV has been reproposed to improve patient prognosis.Nevertheless,this mode is still not routinely used in ARDS patients given its vague definition and complexity.Consequently,in this paper,we summarize the studies that used APRV in ARDS,including adults,children,and animals,to illustrate the settings of parameters,effectiveness in the population,safety(especially in children),incidence,and mechanism of ventilator-induced lung injury(VILI)and effects on extrapulmonary organs.Finally,we found that APRV is likely associated with improvement in ARDS outcomes,and does not increase injury to the lungs and other organs,thereby indicating that personalized APRV settings may be the new hope for ARDS treatment.展开更多
Background:Airway pressure release ventilation(APRV)can be used for cadaveric donor lung recruitment.APRV elevates PaO_(2)in donor lungs;however,reported outcomes in recipients with APRVmanaged donor lungs are limited...Background:Airway pressure release ventilation(APRV)can be used for cadaveric donor lung recruitment.APRV elevates PaO_(2)in donor lungs;however,reported outcomes in recipients with APRVmanaged donor lungs are limited.Methods:We retrospectively reviewed patients who underwent lung transplantation(LTx)from 2012 to 2013 and divided them into two groups based on mode of ventilation used during donor management and organ extraction(A:non-APRV;B:APRV).Kaplan-Meier method and multivariate Cox regression were used for analysis.Results:We found 126 LTx recipients(LTxRs);9 were excluded for use of portable ventilation perfusion systems.Of the remaining 117 patients,81(69%)were in Group A;36(31%)were in Group B.Preoperative LTxR characteristics(age,sex,lung allocation score,endstage lung disease type)were comparable between groups.Donors for Group B were older(P=0.03)and had higher body mass index(BMI)(P<0.001),higher incidence of death from chest trauma(P=0.008),longer ventilation duration after brain death(P<0.001),and higher pre-explant PaO_(2)/FiO_(2)ratios(P<0.001).Post-LTx duration of mechanical ventilation,hospital stay,and median survival were similar in both groups.Risk of death was comparable between the two groups at the end of follow-up(HR=1.42;95%CI:0.57-3.56;P=0.45).Conclusions:APRV is a safe and effective pre-LTx donor lung management strategy.Short-and long-term survival outcomes were comparable in LTx recipients,irrespective of donor ventilation mode.APRV may help recruit lungs from older donors with higher BMI who die from chest trauma and have anticipated longer ventilation duration.展开更多
Mortality from acute respiratory distress syndrome(ARDS) remains unacceptable, approaching 45% in certain high-risk patient populations. Treating fulminant ARDS is currently relegated to supportive care measures only....Mortality from acute respiratory distress syndrome(ARDS) remains unacceptable, approaching 45% in certain high-risk patient populations. Treating fulminant ARDS is currently relegated to supportive care measures only. Thus, the best treatment for ARDS may lie with preventing this syndrome from ever occurring. Clinical studies were examined to determine why ARDS has remained resistant to treatment over the past several decades. In addition, both basic science and clinical studies were examined to determine the impact that early, protective mechanical ventilation may have on preventing the development of ARDS in at-risk patients. Fulminant ARDS is highly resistant to both pharmacologic treatment and methods of mechanical ventilation. However, ARDS is a progressive disease with an early treatment window that can be exploited. In particular, protective mechanical ventilation initiated before the onset of lung injury can prevent the progression to ARDS. Airway pressure release ventilation(APRV) is a novel mechanical ventilation strategy for delivering a protective breath that has been shown to block progressive acute lung injury(ALI) and prevent ALI from progressing to ARDS. ARDS mortality currently remains as high as 45% in some studies. As ARDS is a progressive disease, the key to treatment lies with preventing the disease from ever occurring while it remains subclinical. Early protective mechanical ventilation with APRV appears to offer substantial benefit in this regard and may be the prophylactic treatment of choice for preventing ARDS.展开更多
The standard treatment for acute respiratory distress syndrome(ARDS) is supportive in the form of low tidal volume ventilation applied after significant lung injury has already developed. Nevertheless, ARDS mortality ...The standard treatment for acute respiratory distress syndrome(ARDS) is supportive in the form of low tidal volume ventilation applied after significant lung injury has already developed. Nevertheless, ARDS mortality remains unacceptably high(> 40%). Indeed, once ARDS is established it becomes refractory to treatment, and therefore avoidance is key. However, preventive techniques and therapeutics to reduce the incidence of ARDS in patients at high-risk have not been validated clinically. This review discusses the current data suggesting that preemptive application of the properly adjusted mechanical breath can block progressive acute lung injury and significantly reduce the occurrence of ARDS.展开更多
文摘The following case describes the favorable application of airway pressure release ventilation (APRV) in a patient with pulmonary hypertension who developed respiratory failure and abdominal compartment syndrome after abdominal closure from an incarcerated umbilical hernia. A 66-year-old male with past medical history of restrictive lung disease, obstructive sleep apnea and pulmonary hypertension, presented to the operating room for an incarcerated inguinal hernia. After abdominal closure, he gradually developed decreased oxygen saturation and hypotension. APRV was initiated during post operative day 2 after inability to maintain adequate oxygen saturation with resultant hypotension on pressure control ventilation with varying degrees of positive end expiratory pressure and 100% inspired oxygen concentration. The initial set high pressure on APRV was 35 mm Hg. Yet, in lieu of decreasing lung compliance, it peaked at 50 mm Hg. Eventually, inhaled Nitric Oxide was initiated post operative day 3 due to increasing pulmonary arterial pressures. A bedside laparotomy was eventually performed when bladder pressures peaked to 25 mm Hg. APRV gradually and temporally improved the oxygen saturation and decreased the pulmonary arterial pressures with subsequent increase in systemic blood pressures. APRV promoted alveolar recruitment and decreased the shunting associated with abdominal compartment syndrome. Better oxygen saturations lead to increases in blood pressure by decreasing the effects of hypoxic pulmonary vasoconstriction on the right ventricle (RV). In patients with decreasing lung compliance and pulmonary comorbidities, APRV appears safe and allows for improve oxygenation, after failure with conventional modes of ventilation.
基金supported by the National Natural Science Foundation of China(gereral program,Grant No.81,873,929)。
文摘Mechanical ventilation(MV)is an essential life support method for patients with acute respiratory distress syn-drome(ARDS),which is one of the most common critical illnesses with high mortality in the intensive care unit(ICU).A lung-protective ventilation strategy based on low tidal volume(LTV)has been recommended since a few years;however,as this did not result in a significant decrease of ARDS-related mortality,a more optimal venti-lation mode was required.Airway pressure release ventilation(APRV)is an old method defined as a continuous positive airway pressure(CPAP)with a brief intermittent release phase based on the open lung concept;it also perfectly fits the ARDS treatment principle.Despite this,APRV has not been widely used in the past,rather only as a rescue measure for ARDS patients who are difficult to oxygenate.Over recent years,with an increased under-standing of the pathophysiology of ARDS,APRV has been reproposed to improve patient prognosis.Nevertheless,this mode is still not routinely used in ARDS patients given its vague definition and complexity.Consequently,in this paper,we summarize the studies that used APRV in ARDS,including adults,children,and animals,to illustrate the settings of parameters,effectiveness in the population,safety(especially in children),incidence,and mechanism of ventilator-induced lung injury(VILI)and effects on extrapulmonary organs.Finally,we found that APRV is likely associated with improvement in ARDS outcomes,and does not increase injury to the lungs and other organs,thereby indicating that personalized APRV settings may be the new hope for ARDS treatment.
文摘Background:Airway pressure release ventilation(APRV)can be used for cadaveric donor lung recruitment.APRV elevates PaO_(2)in donor lungs;however,reported outcomes in recipients with APRVmanaged donor lungs are limited.Methods:We retrospectively reviewed patients who underwent lung transplantation(LTx)from 2012 to 2013 and divided them into two groups based on mode of ventilation used during donor management and organ extraction(A:non-APRV;B:APRV).Kaplan-Meier method and multivariate Cox regression were used for analysis.Results:We found 126 LTx recipients(LTxRs);9 were excluded for use of portable ventilation perfusion systems.Of the remaining 117 patients,81(69%)were in Group A;36(31%)were in Group B.Preoperative LTxR characteristics(age,sex,lung allocation score,endstage lung disease type)were comparable between groups.Donors for Group B were older(P=0.03)and had higher body mass index(BMI)(P<0.001),higher incidence of death from chest trauma(P=0.008),longer ventilation duration after brain death(P<0.001),and higher pre-explant PaO_(2)/FiO_(2)ratios(P<0.001).Post-LTx duration of mechanical ventilation,hospital stay,and median survival were similar in both groups.Risk of death was comparable between the two groups at the end of follow-up(HR=1.42;95%CI:0.57-3.56;P=0.45).Conclusions:APRV is a safe and effective pre-LTx donor lung management strategy.Short-and long-term survival outcomes were comparable in LTx recipients,irrespective of donor ventilation mode.APRV may help recruit lungs from older donors with higher BMI who die from chest trauma and have anticipated longer ventilation duration.
文摘Mortality from acute respiratory distress syndrome(ARDS) remains unacceptable, approaching 45% in certain high-risk patient populations. Treating fulminant ARDS is currently relegated to supportive care measures only. Thus, the best treatment for ARDS may lie with preventing this syndrome from ever occurring. Clinical studies were examined to determine why ARDS has remained resistant to treatment over the past several decades. In addition, both basic science and clinical studies were examined to determine the impact that early, protective mechanical ventilation may have on preventing the development of ARDS in at-risk patients. Fulminant ARDS is highly resistant to both pharmacologic treatment and methods of mechanical ventilation. However, ARDS is a progressive disease with an early treatment window that can be exploited. In particular, protective mechanical ventilation initiated before the onset of lung injury can prevent the progression to ARDS. Airway pressure release ventilation(APRV) is a novel mechanical ventilation strategy for delivering a protective breath that has been shown to block progressive acute lung injury(ALI) and prevent ALI from progressing to ARDS. ARDS mortality currently remains as high as 45% in some studies. As ARDS is a progressive disease, the key to treatment lies with preventing the disease from ever occurring while it remains subclinical. Early protective mechanical ventilation with APRV appears to offer substantial benefit in this regard and may be the prophylactic treatment of choice for preventing ARDS.
文摘The standard treatment for acute respiratory distress syndrome(ARDS) is supportive in the form of low tidal volume ventilation applied after significant lung injury has already developed. Nevertheless, ARDS mortality remains unacceptably high(> 40%). Indeed, once ARDS is established it becomes refractory to treatment, and therefore avoidance is key. However, preventive techniques and therapeutics to reduce the incidence of ARDS in patients at high-risk have not been validated clinically. This review discusses the current data suggesting that preemptive application of the properly adjusted mechanical breath can block progressive acute lung injury and significantly reduce the occurrence of ARDS.
