The ARDS Network low-tidal-volume protocol is considered the standard of care for patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). The protocol is built on the foundation of low-tidal-volume ventilation, use of a combined PEEP and FIO2 table, and managing alveolar end-inspiratory pressure by limiting the plateau airway pressure to ≤ 30 cm H2O. Although this strategy, to date, is the only method that significantly improves ALI/ARDS survival, alternative methods of improving hypoxemia and minimizing ventilator-induced lung injury, in conjunction with low-tidal-volume ventilation, can be used for life-threatening ARDS. We present a case in which we customized the use of alveolar recruitment maneuvers by analyzing the hysteresis of the pressure-volume curve to assess lung recruitability, decremental PEEP to sustain lung recruitment, and careful use of plateau pressure ≥ 30 cm H2O, which improved our patient's life-threatening hypoxemia within the first 36 min of arrival to our ICU.
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med, 2000; 342(18):1301–1308.
2.
BernardGR, ArtigasA, BrighamKL, CarletJ, FalkeK, HudsonL, et al. The American-European consensus conference on ARDS: definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med, 1994; 149(3 Pt 1):818–824.
3.
DemoryD, ArnalJ-M, WysockiM, DonatiS, GranierI, CornoGaelle, Durand-GaselinJ. Recruitability of the lung estimated by the pressure volume curve hysteresis in ARDS. Intensive Care Med, 2008; 34(11):2019–2025.
4.
HicklingKG. Best compliance during a decremental, but not incremental, PEEP trial is related to open-lung PEEP: a mathematical model of acute respiratory distress syndrome lungs. Am J Respir Crit Care Med, 2001; 163(1):69–78.
5.
GirgisK, HamedH, KhaterY, KacmarekR. A decremental PEEP trial identifies the PEEP level that maintains oxygenation after lung recruitment. Respir Care, 2006; 51(10):1132–1139.
6.
MeadeM, CookD, GuyattG, SlutskyA, ArabiY, CooperD, et al. Ventilation strategy using low tidal volumes, recruitment maneuvers, and high PEEP for acute lung injury and acute respiratory distress syndrome. JAMA, 2008; 299(6):637–645.
7.
WheelerAP, BernardGR, ThrompsonB, SchoenfeldD, WiedemannHP, de BoisblancBet al; National Heart, Lung, and Blood Institute; ARDS Clinical Trials Network. Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med, 2006; 354(21):2213–2224.
8.
WiedemannHP, WheelerAP, BernardGR, ThompsonBT, HaydenD, de BoisblancBet al; National Heart, Lung, and Blood Institute; ARDS Clinical Trials Network. Comparison of 2 fluid-management strategies in acute lung injury. N Engl J Med, 2006; 354(24):2564–2575.
9.
AmatoMBP, BarbasCSV, MedeirosDM, SchettinoP, Lorenzi-FilhoG, KairallaRA, et al. Beneficial effects of the “open lung approach” with low distending pressures in acute respiratory distress syndrome: a prospective randomized study on mechanical ventilation. Am J Respir Crit Care Med, 1995; 152(6):1835–1846.
10.
BarbasCS. Lung recruitment manuevers in acute respiratory distress syndrome and facilitating resolution. Crit Care Med, 2003; 31(4):S265–S271.
11.
LimSC, AdamsAB, SimonsonDA, DriesDJ, BroccardAF, HotchkissJR, MariniJJ. Intercomparison of recruitment maneuver efficacy in 3 models of acute lung injury. Crit Care Med, 2004; 32(12):2371–2377.
12.
OczenskiW, HormannC, KellerC, LorenziN, KepkaA, SchwarzS, FitzgeraldR. Recruitment Maneuvers after a PEEP trial do not induce sustained effects in early adult respiratory distress syndrome. Anethesiology, 2004; 101(3):620–625.
13.
TugrulS, AkinciO, OzcanP, InceS, EsenF, TelciL, et al. Effects of sustained inflation and postinflation PEEP in acute respiratory distress syndrome: focusing on pulmonary and extrapulmonary forms. Crit Care Med, 2003; 31(3):738–744.
14.
BorgesJB, OkamotoVN, MatosGF, CaramezMP, ArantesPR, BarrosF, et al. Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome. Am J Respir Crit Care Med, 2006; 174(3):268–278.
15.
GatinoniL, CaironiP, CressoniM, ChiumelloD, RanieriM, QuintelM, et al. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med, 2006; 354(17):1775–1786.
16.
PiacentiE, WysockiM, BlanchL. A new automated method versus continuous positive airway pressure method for measuring pressure-volume curves in patients with acute lung injury. Intensive Care Med, 2009; 35(3):565–570.
17.
Koefoed-NeilsenJ, AndersenG, BarklinA, BachA, LundeS, TonnesenE, et al. Maximal hysteresis: a new method to set PEEP in acute lung injury. Acta Anaesthesiol Scand, 2008; 52(5):641–649.
18.
SlutskyA. Ventilator induced lung injury: from barotrauma to biotrauma. Respir Care, 2005; 50(5):646–659.
19.
GrassoS, MasciaL, Del TurcoM, MalacarneP, GiuntaF, BrochardL, et al. Effects of recruiting maneuvers in patients with acute respiratory distress syndrome ventilated with protective ventilatory strategy. Anesthesiology, 2002; 96(4):795–802.
20.
LapinskySE, AubinM, MehtaS, BoiteauP, SlutskyAS. Safety and efficacy of a sustained inflation for alveolar recruitment in adults with respiratory failure. Intensive Care Med, 1999; 25(11):1297–1301.
21.
TalmorD, SargeT, MalhotraA, O'DonnellC, RitzR, LisbonA, et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med; 359(20):2095–2104.
22.
ChiumelloD, CarlessoE, CadringerP, CaironiP, ValenzeF, PolliF, et al. Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome. Am J Respir Crit Care Med, 2008; 178(4):346–355.
