A number of adjuncts to mechanical ventilation have been the focus of recent research. Automatic tube compensation (the regulation of airway pressure by estimation of tracheal pressure) appears to be an ideal approach to unloading the resistive effort imposed by the endotracheal tube. Randomized controlled trials have recently been performed with high frequency oscillation (HFO), partial liquid ventilation (PLV), and prone positioning. Unfortunately, all of those trials were negative; however, it appears the only technique that will be abandoned for the near future is PLV. The HFO trial trended toward benefit with HFO, and one must question the protocol used in the prone positioning trial. With both HFO and prone positioning we will have to wait for additional randomized clinical trials before the status of those techniques can be determined. No randomized trials of tracheal gas insufflation have been performed. Of major concern with tracheal gas insufflation is the lack of a commercial product.
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References
1.
ShapiroM, WilsonRK, CasarG, BloomK, TeagueRB. Work of breathing through different sized endotracheal tubes. Crit Care Med1986;14(12):1028–1031.
2.
BolderPM, HealyTEJ, BolderAR, BeattyPCW, KayB.The extra work of breathing through adult endotracheal tubes. Anesth Analg1986;65(8):853–859.
3.
FiastroFJ, HabibMP, QuanSF. Pressure support compensation for inspiratory work due to endotracheal tubes and demand continuous positive airway pressure. Chest1988;93(3):499–505.
4.
BannerMJ, BlanchPB, KirbyRR. Imposed work of breathing and methods of triggering a demand-flow, continuous positive airway pressure system. Crit Care Med1993;21(2):183–190.
5.
TakeuchiM, WilliamsP, HessD, KacmarekRM. Continuous positive airway pressure in new-generation mechanical ventilators: a lung model study. Anesthesiology (2002, in press).
6.
BrochardL, RuaF, LorinoH, LemaireF, HarfA.Inspiratory pressure support compensates for the additional work of breathing caused by the endotracheal tube. Anesthesiology1991;75(5):739–745.
7.
StrausC, LouisB, IsabeyD, LemaireF, HarfA, BrochardL.Contribution of the endotracheal tube and the upper airway to breathing workload. Am J Respir Crit Care Med1998;157(1):23–30.
8.
DiehlJL, IsabeyD, DesmaraisG, BrochardL, HarfA, LofasoF.Physiological effects of alveolar, tracheal, and "standard" pressure supports. J Appl Physiol1999;87(1):428–437.
9.
StockerR, FabryB, EberhardL, HaberthurC.Support of spontaneous breathing in the intubated patient: automatic tube compensation (ATC) and proportional assist ventilation (PAV). Acta Anaesthesiol Scand1997;111:123–128.
10.
WriggeH, ZinserlingJ, HeringR, SchwalfenbergN, StuberF, von SpiegelT, . Cardiorespiratory effects of automatic tube compensation during airway pressure release ventilation in patients with acute lung injury. Anesthesiology2001;95(2):382–389.
11.
GuttmannJ, EberhardL, FabryB, BertschmannW, WolffG.Continuous calculation of intratracheal pressure in tracheally intubated patients. Anesthesiology1993;79(3):503–513.
12.
GuttmannJ, KesslerV, MolsG, HentschelR, HaberthurC, GeigerK.Continuous calculation of intratracheal pressure in the presence of pediatric endotracheal tubes. Crit Care Med2000;28(4):1018–1026.
13.
KuhlenR, RossaintR.Electronic extubation: is it worth trying?Intensive Care Med1997;23(11):1105–1107.
14.
KuhlenR, MaxM, NibbeL, HausmannS, SprengerM, FalkeK, RossaintR.[Respiratory pattern and respiratory strain in automatic tube compensation and inspiratory pressure support.]Anaesthesist1999;48(12):871–875.
15.
FabryB, HaberthurC, ZappeD, GuttmannJ, KuhlenR, StockerR.Breathing pattern and additional work of breathing in spontaneously breathing patients with different ventilatory demands during inspiratory pressure support and automatic tube compensation. Intensive Care Med1997;23(5):545–552.
16.
HaberthurC, FabryB, StockerR, RitzR, GuttmannJ.Additional inspiratory work of breathing imposed by tracheostomy tubes and non-ideal ventilator properties in critically ill patients. Intensive Care Med1999;25(5):514–519.
17.
GuttmannJ, BernhardH, MolsG, BenzingA, HofmannP, HaberthurC, . Respiratory comfort of automatic tube compensation and inspiratory pressure support in conscious humans. Intensive Care Med1997;23(11):1119–1124.
18.
MolsG, RohrE, BenzincA, HaberthurC, GeigerK, GuttmannJ.Breathing pattern associated with respiratory comfort during automatic tube compensation and pressure support ventilation in normal subjects. Acta Anaesthesiol Scand2000;44(3):223–230.
19.
FroeseAB. High-frequency oscillatory ventilation for adult respiratory distress syndrome: let's get it right this time!Crit Care Med1997;25(6):906–908.
20.
GerstmannDR, MintonSD, StoddardRA, MeredithKS, MonacoF, BertrandJM, . The Provo multicenter early high-frequency oscillatory ventilation trial: improved pulmonary and clinical outcome in respiratory distress syndrome. Pediatrics1996;98(6 Pt 1):1044–1057.
21.
PlavkaR, KopeckyP, SebronV, SvihovecP, ZlatohlavkovaB, JanusV.A prospective randomized comparison of conventional mechanical ventilation and very early high frequency oscillatory ventilation in extremely premature newborns with respiratory distress syndrome. Intensive Care Med1999;25(1):68–75.
22.
ClarkRH, GerstmannDR, NullDMJr, deLemosRA. Prospective randomized comparison of high-frequency oscillatory and conventional ventilation in respiratory distress syndrome. Pediatrics1992;89(1):5–12.
23.
OgawaY, MiyasakaK, KawanoT, ImuraS, InukaiK, OkuyamaK, . A multicenter randomized trial of high frequency oscillatory ventilation as compared with conventional mechanical ventilation in preterm infants with respiratory failure. Early Hum Dev1993;32(1):1–10.
24.
HiFO Study Group. Randomized study of high-frequency oscillatory ventilation in infants with severe respiratory distress syndrome. J Pediatr1993;122(4):609–619.
25.
ClarkRH, YoderA, SellMS. Prospective, randomized comparison of high-frequency oscillation and conventional ventilation in candidates for extracorporeal membrane oxygenation. J Pediatr1994;124(3):447–454.
26.
The HIFI Study Group. High-frequency oscillatory ventilation compared with conventional mechanical ventilation in the treatment of respiratory failure in pre-term infants. N Engl J Med1989;320(2):88–93.
27.
Rettwitz-VolkW, VeldmanA, RothB, VierzigA, KachelW, VarnboltV, . A prospective, randomized, multicenter trial of high-frequency oscillatory ventilation compared with conventional ventilation in preterm infants with respiratory distress syndrome receiving surfactant. J Pediatr1998;132(2):249–254.
28.
MorietteG, Paris-LladoJ, WaltiH, EscandeB, MagnyJF, CambonieG, . Prospective randomized multicenter comparison of high-frequency oscillatory ventilation and conventional ventilation in preterm infants of less than 30 weeks with respiratory distress syndrome. Pediatrics2001;107(2):363–372.
29.
ThomeUH, CarloWA. High-frequency ventilation in neonates. Am J Perinatal2000;17(1):1–9.
30.
FortP, FarmerC, WestermanJ, JohnannigmanJ, BeninotiW, DolanS, DerdakS.High-frequency oscillatory ventilation for adult respiratory distress syndrome: a pilot study. Crit Care Med1997;25(6):937–947.
31.
MehtaS, LapinskySE, HallettDC, MerkerD, GrollRJ, CooperAB, . Prospective trial of high-frequency oscillation in adults with acute respiratory distress syndrome. Crit Care Med2001;29(7):1360–1369.
32.
RavenscraftSA. Tracheal gas insufflation: adjunct to conventional mechanical ventilation. Respir Care1996;41(2):105–111.
33.
KacmarekRM. Complications of tracheal gas insufflation. Respir Care2001;46(2):167–176.
34.
NahumA.Animal and lung model studies of tracheal gas insufflation. Respir Care2001;46(2):149–157.
35.
ImanakaH, KacmarekRM, RitzR, HessD.Tracheal gas insufflation-pressure control versus volume control ventilation: a lung model study. Am J Respir Crit Care Med1996;153(3):1019–1024.
36.
ImanakaH, KirmseM, MangH, HessD, KacmarekRM. Expiratory phase tracheal gas insufflation and pressure control in sheep with permissive hypercapnia. Am J Respir Crit Care Med1999;159(1):49–54.
37.
KirmseM, FujinoY, HromiJ, MangH, HessD, KacmarekRM. Pressure-release tracheal gas insufflation reduces airway pressures in lung-injured sheep maintaining eucapnia. Am J Respir Crit Care1999;160(5 Pt 1):1462–1467.
38.
DelgadoE, MiroAM, HoffmanLA, TasotaFJ, PinskyMR. Continuous and expiratory tracheal gas insufflation produce equal levels of total PEEP. Respir Care1999;44(4):428–433.
39.
ImanakaH, KacmarekRM, RiggiV, RitzR, HessD.Expiratory phase and volume-adjusted tracheal gas insufflation: a lung model study. Crit Care Med1998;26(5):939–946.
40.
BlanchLL. Clinical studies of tracheal gas insufflation. Respir Care2001;46(2):158–166.
41.
FuhrmanBP, PaczanPR, DeFrancisisM.Perfluorocarbon-associated gas exchange. Crit Care Med1991;19(5):712–722.
42.
TütüncüAS, FaithfullNS, LachmannB.Comparison of ventilatory support with intratracheal perfluorocarbon administration and conventional mechanical ventilation in animals with acute respiratory failure. Am Rev Respir Dis1993;148(3):785–792.
43.
PapoMC, PaczanPR, FuhrmanBP, SteinhornDM, HernanLJ, LeachCL, . Perfluorocarbon-associated gas exchange improves oxygenation, lung mechanics, and survival in a model of adult respiratory distress syndrome. Crit Care Med1996;24(3):466–474.
44.
GaugerPG, OverbeckMC, ChambersSD, CailipanCI, HirschlRB. Partial liquid ventilation improves gas exchange and increases EELV in acute lung injury. J Appl Physiol1998;84(5):1566–1572.
45.
LangeNR, KozlowskiJK, GustR, ShapiroSD, SchusterDP. Effect of partial liquid ventilation on pulmonary vascular permeability and edema after experimental acute lung injury. Am J Respir Crit Care Med2000;162(1):271–277.
46.
LoerSA, TarnowJ.Partial liquid ventilation reduces fluid filtration of isolated rabbit lungs with acute hydrochloric acid-induced edema. Anesthesiology2001;94(6):1045–1049.
47.
DicksonEW, HeardSO, ChuB, FraireA, BrueggemannAB, DoernGV. Partial liquid ventilation with perfluorocarbon in the treatment of rats with lethal pneumococal pneumonia. Anesthesiology1998;88(1):218–223.
48.
SajanI, ScannapiecoFA, FuhrmanBP, SteinhornDM. The risk of nosocomial pneumonia is not increased during partial liquid ventilation. Crit Care Med1999;27(12):2741–2747.
49.
QuintelM, HeineM, HirschlRB, TillmannsR, WessendorfV.Effects of partial liquid ventilation on lung injury in a model of acute respiratory failure: a histologic and morphometric analysis. Crit Care Med1998;26(5):833–843.
50.
MoomeyCBJr, FabianTC, CroceMA, MeltonSM, ProctorKG. Cardiopulmonary function after pulmonary contusion and partial liquid ventilation. J Trauma1998;45(2):283–290.
51.
LeachCL, HolmB, MorinFC3rd, FuhrmanBP, PapoMC, SteinhornD, HernanLJ. Partial liquid ventilation in premature lambs with respiratory distress syndrome: efficacy and compatibility with exogenous surfactant. J Pediatr1995;126(3):412–420.
Tarczy-HornochP, HildebrandtJ, StandaertTA, JacksonJC. Surfactant replacement increases compliance in premature lambs lung during partial liquid ventilation in situ. J Appl Physiol1998;84(4):1316–1322.
54.
RicardJD, Martin-LefevreL, DreyfussD, SaumonG.Alveolar permeability and liquid absorption during partial liquid ventilation of rats with perflubron. Am J Respir Crit Care Med2000;161(1):44–49.
55.
YoungerJG, TaqiAS, TillGO, HirschlRB. Patrial liquid ventilation protects lung during resuscitation from shock. J Appl Physiol1997;83(5):1666–1670.
56.
SteinhornDM, SmithTM, FuhrmanBP. Liquid perfluorocarbon affects phagocytosis by alveolar macrophages after in vitro exposure (abstract). Crit Care Med1995;23:A195.
57.
SteinhornDM, PapoMC, AljadaA, ThusuK, FuhrmanBP, DandonaP.Partial liquid ventilation (PLV) with perflubron decreases oxidative damage to the lung during experimental injury (abstract). Crit Care Med1996;24:A148.
58.
SmithTM, SteinhornDM, ThusuK, FuhrmanBP, DandonaP.A liquid perfluorochemical decreases the in vitro production of reactive oxygen species by alveolar macrophages. Crit Care Med1995;23(9):1533–1539.
59.
WilliamsEA, WeltySE, GeskeRS, HubbleCL, CraigDM, QuickG, . Liquid lung ventilation reduces neutrophil sequestration in a neonatal swine model of cardiopulmonary bypass. Crit Care Med2001;29(4):789–795.
60.
ItanoH, AoeM, IchibaS, YamashitaM, DateH, AndouA, ShimizuN.Partial liquid ventilation for acute allograft dysfunction after canine lung transplantation. Ann Thorac Surg1999;67(2):332–339.
61.
HarringtonDT, JordanBS, DubickMA, CancioLC, BrinkleyW, KimS, . Delayed partial liquid ventilation shows no efficacy in the treatment of smoke inhalation injury in swine. J Appl Physiol2001;90(6):2351–2360.
62.
HirschlRB, PranikoffT, GaugerP, SchreinerRJ, DechertR, BartlettRH. Liquid ventilation in adults, children, and full-term neonates. Lancet1995;346(8984):1201–1202.
63.
HirschlRB, PranikoffT, WiseC, OverbeckMC, GaugerP, SchreinerRJ, . Initial experience with partial liquid ventilation in adult patients with the acute respiratory distress syndrome. JAMA1996;275(5):383–389.
64.
LeachCL, GreenspanJS, RubensteinSD, ShafferTH, WolfsonMR, JacksonJC, . Partial liquid ventilation with perflubron in premature infants with severe respiratory distress syndrome. N Engl J Med1996;335(11):761–767.
65.
CroceMA, FabianTC, PattonJHJr, MeltonSM, MooreM, TrenthamLL. Partial liquid ventilation decreases the inflammatory response in the alveolar environment of trauma patients. J Trauma1998;45(2):273–282.
66.
TsaiWC, LewisD, NasrSZ, HirschlRB. Liquid ventilation in an infant with pulmonary alveolar proteinosis. Pediatr Pulmonol1998;26(4):283–286.
67.
ReickertC, PranikoffT, OverbeckM, KazerooniE, MasseyK, BartlettR, HirschlR.The pulmonary and systemic distribution and elimination of perflubron from adult patients treated with partial liquid ventilation. Chest2001;119(2):515–522.
GreenspanJS, WolfsonMR, RubensteinSD, ShafferTH. Liquid ventilation of human preterm neonates. J Pediatr1990;117(1 Pt 1):106–111.
70.
HirschlRB, TooleyR, ParentAC, JohnsonK, BartlettRH. Improvement of gas exchange, pulmonary function, and lung injury with partial liquid ventilation: a study model in a setting of severe respiratory failure. Chest1995;108(2):500–508.
71.
BarlettR, CroceM, HirschlR, GoreD, WiedemannH, DavisR, . A phase II randomized, controlled tried of partial liquid ventilation (PLV) in adult patients with acute hypoxemic respiratory failure (AHRF) (abstract). Crit Care Med1997;25:A35.
72.
PappertD, RossaintR, SlamaK, GruningT, FalkeKJ. Influence of positioning on ventilation-perfusion relationships in severe adult respiratory distress syndrome. Chest1994;106(5):1511–1516.
73.
ChatteG, SabJM, DuboisJM, SirodotM, GaussorguesP, RobertD.Prone position in mechanically ventilated patients with severe acute respiratory failure. Am J Respir Crit Care Med1997;155(2):473–478.
74.
FridrichP, KrafftP, HochleuthnerH, MauritzW.The effects of long-term prone positioning in patients with trauma-induced adult respiratory distress syndrome. Anes Analg1996;83(6):1206–1211.
75.
BlanchL, ManceboJ, PerezM, MartinezM, MasA, BetbeseAJ, . Short-term effects of prone position in critically ill patients with acute respiratory distress syndrome. Intensive Care Med1997;23(10):1033–1039.
76.
JollietP, BulpaP, ChevroletJC. Effect of the prone position on gas exchange and hemodynamics is severe acute respiratory distress syndrome. Crit Care Med1998;26(12):1977–1985.
77.
JollietP, BulpaP, RitzM, RicouB, LopezJ, ChevroletJC. Additional beneficial effects of prone position, nitric oxide, and almitrine bimesylate on gas exchange and oxygen transport in the acute respiratory distress syndrome. Crit Care Med1997;25(5):786–794.
78.
MureM, MartlingCR, LindahlSG. Dramatic effect on oxygenation in patients with severe acute lung insufficiency treated in the prone position. Crit Care Med1997;25(9):1539–1544.
79.
LammWJ, GrahamMM, AlbertRK. Mechanism by which the prone position improves oxygenation in acute lung injury. Am J Respir Crit Care Med1994;150(1):184–193.
80.
GattinoniL, PelosiP, VitaleG, PesentiA, D'AndreaL, MascheroniD.Body position changes redistribute lung computed-tomographic density in patients with acute respiratory failure. Anesthesiology1991;74(1):15–23.
81.
Lai-FookSJ, RodarteJR. Pleural pressure distribution and its relationship to lung volume and interstitial pressure. J Appl Physiol1991;70(3):967–978.
82.
MureM, GlennyRW, DominoKB, HlastalaMP. Pulmonary gas exchange improves in the prone position with abdominal distension. Am J Respir Crit Care Med1998;157(6 Pt 1):1785–1790.
83.
PelosiP, TubioloD, MascheroniD, VicardiP, CrottiS, ValenzaF, GattinoniL.Effects of the prone position on respiratory mechanica and gas exchange during acute lung injury. Am J Respir Crit Care Med1998;157(2):387–393.
84.
GlennyRW, LammWJ, AlbertRK, RobertsonHT. Gravity is a minor determinant of pulmonary blood flow distribution. J Appl Physiol1991;71(2):620–629.
85.
MutohT, GuestRJ, LammWJ, AlbertRK. Prone position alters the effect of volume overload on regional pleural pressures and improves hypoxemia in pigs in vivo. Am Rev Respir Dis1992;146(2):300–306.
86.
NyrenS, MureM, JacobssonH, LarssonSA, LindahlSG. Pulmonary perfusion is more uniform in the prone than in the supine position: scintigraphy in healthy humans. J Appl Physiol1999;86(4):1135–1141.
87.
GattinoiniL, TognoniG, PesentiA, TacconeP, MascheroniD, LabartaV, . Effect of prone positioning on the survival of patients with acute respiratory failure. N Engl J Med2001;345(8):568–573.
88.
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes compared to traditional tidal volume for acute lung injury and the acute respiratory distress syndrome. N Engl J Med2000;342(18):1301–1308.
89.
KacmarekRM, SchwartzDR. Lung recruitment. Respir Care Clin N Am2000;6(4):597–623.
