Am. J. Respir. Crit. Care Med., Volume 159, Number 4, April 1999, 1241-1248

Spontaneous Breathing During Ventilatory Support Improves Ventilation-Perfusion Distributions in Patients with Acute Respiratory Distress Syndrome

CHRISTIAN PUTENSEN, NORBERT J. MUTZ, GABRIELE PUTENSEN-HIMMER, and JÖRG ZINSERLING

Department of Anesthesiology and Intensive Care Medicine, University of Bonn, Bonn, Germany; and Division of Intensive Care Medicine, Department of Anesthesia and Intensive Care Medicine, University of Innsbruck, Innsbruck, Austria

Ventilation-perfusion ( A/) distributions were evaluated in 24 patients with acute respiratory distress syndrome (ARDS), during airway pressure release ventilation (APRV) with and without spontaneous breathing, or during pressure support ventilation (PSV). Whereas PSV provides mechanical assistance of each inspiration, APRV allows unrestricted spontaneous breathing throughout the mechanical ventilation. Patients were randomly assigned to receive APRV and PSV with equal airway pressure limits (Paw) (n = 12) or minute ventilation ( E) (n = 12). In both groups spontaneous breathing during APRV was associated with increases (p < 0.05) in right ventricular end-diastolic volume, stroke volume, cardiac index (CI), Pa_O2, oxygen delivery, and mixed venous oxygen tension (Pv_O2) and with reductions (p < 0.05) in pulmonary vascular resistance and oxygen extraction. PSV did not consistently improve CI and Pa_O2 when compared with APRV without spontaneous breathing. Improved A/ matching during spontaneous breathing with APRV was evidenced by decreases in intrapulmonary shunt (equal Paw: 33 ± 4 to 24 ± 4%; equal E: 32 ± 4 to 25 ± 2%) (p < 0.05), dead space (equal Paw: 44 ± 9 to 38 ± 6%; equal E: 44 ± 9 to 38 ± 6%) (p < 0.05), and the dispersions of ventilation (equal Paw: 0.96 ± 0.23 to 0.78 ± 0.22; equal E: 0.92 ± 0.23 to 0.79 ± 0.22) (p < 0.05), and pulmonary blood flow distribution (equal Paw: 0.89 ± 0.12 to 0.72 ± 0.10; equal E: 0.94 ± 0.19 to 0.78 ± 0.22) (p < 0.05). PSV did not improve A/ distributions when compared with APRV without spontaneous breathing. These findings indicate that uncoupling of spontaneous and mechanical ventilation during APRV improves A/ matching in ARDS presumably by recruiting nonventilated lung units. Apparently, mechanical assistance of each inspiration during PSV is not sufficient to counteract the A/ maldistribution caused by alveolar collapse in patients with ARDS.

This article has been cited by other articles:

				T. Yoshida, H. Rinka, A. Kaji, A. Yoshimoto, H. Arimoto, T. Miyaichi, and M. Kan The Impact of Spontaneous Ventilation on Distribution of Lung Aeration in Patients with Acute Respiratory Distress Syndrome: Airway Pressure Release Ventilation Versus Pressure Support Ventilation Anesth. Analg., December 1, 2009; 109(6): 1892 - 1900. [Abstract] [Full Text] [PDF]

				A. R. Carvalho, P. M. Spieth, P. Pelosi, A. Beda, A. J. Lopes, B. Neykova, A. R. Heller, T. Koch, and M. Gama de Abreu Pressure Support Ventilation and Biphasic Positive Airway Pressure Improve Oxygenation by Redistribution of Pulmonary Blood Flow Anesth. Analg., September 1, 2009; 109(3): 856 - 865. [Abstract] [Full Text] [PDF]

				S.P. Stawicki, M. Goyal, and B. Sarani Analytic Reviews: High-Frequency Oscillatory Ventilation (HFOV) and Airway Pressure Release Ventilation (APRV): A Practical Guide J Intensive Care Med, July 1, 2009; 24(4): 215 - 229. [Abstract] [PDF]

				T. Varpula, P. Valta, A. Markkola, K. Pohjanen, J. Halavaara, M. Hynynen, and V. Pettila The Effects of Ventilatory Mode on Lung Aeration Assessed With Computer Tomography: A Randomized Controlled Study J Intensive Care Med, March 1, 2009; 24(2): 122 - 130. [Abstract] [PDF]

				H. Heinze, B. Sedemund-Adib, M. Heringlake, T. Meier, and W. Eichler Changes in Functional Residual Capacity During Weaning from Mechanical Ventilation: A Pilot Study Anesth. Analg., March 1, 2009; 108(3): 911 - 915. [Abstract] [Full Text] [PDF]

				C. N. Sessler Mechanical Ventilatory Support ACCP Pulmonary Med Brd Rev, January 1, 2009; 25(0): 457 - 478. [Full Text] [PDF]

				M. Hommel, M. Deja, V. von Dossow, K. Diemel, C. Heidenhain, C. Spies, and S. Weber-Carstens Bronchial fistulae in ARDS patients: management with an extracorporeal lung assist device Eur. Respir. J., December 1, 2008; 32(6): 1652 - 1655. [Abstract] [Full Text] [PDF]

				E. Fan, P. Khatri, P. A. Mendez-Tellez, C. Shanholtz, and D. M. Needham Review of A Large Clinical Series: Sedation and Analgesia Usage with Airway Pressure Release and Assist-control Ventilation for Acute Lung Injury J Intensive Care Med, November 1, 2008; 23(6): 376 - 383. [Abstract] [PDF]

				R. M. Effros, P. Pornsuriyasak, J. Porszasz, and R. Casaburi Indicator dilution measurements of extravascular lung water: basic assumptions and observations Am J Physiol Lung Cell Mol Physiol, June 1, 2008; 294(6): L1023 - L1031. [Abstract] [Full Text] [PDF]

				T. D. Girard and G. R. Bernard Mechanical Ventilation in ARDS: A State-of-the-Art Review Chest, March 1, 2007; 131(3): 921 - 929. [Abstract] [Full Text] [PDF]

				R. Hering, J. Zinserling, H. Wrigge, D. Varelmann, A. Berg, S. Kreyer, and C. Putensen Effects of Spontaneous Breathing During Airway Pressure Release Ventilation on Respiratory Work and Muscle Blood Flow in Experimental Lung Injury Chest, October 1, 2005; 128(4): 2991 - 2998. [Abstract] [Full Text] [PDF]

				L. Magnusson and D. R. Spahn New concepts of atelectasis during general anaesthesia Br. J. Anaesth., July 1, 2003; 91(1): 61 - 72. [Full Text] [PDF]

				J J Cordingley and B F Keogh The pulmonary physician in critical care {middle dot} 8: Ventilatory management of ALI/ARDS Thorax, August 1, 2002; 57(8): 729 - 734. [Abstract] [Full Text] [PDF]

				N. M. Habashi, J. O'Connor, and M. McCunn Venilator Management and Criical Care Issues Following Cardiothoracic Trauma Seminars in Cardiothoracic and Vascular Anesthesia, June 1, 2002; 6(2): 127 - 147. [Abstract] [PDF]

				R. Dembinski, M. Max, R. Bensberg, R. Rossaint, and R. Kuhlen Pressure Support Compared with Controlled Mechanical Ventilation in Experimental Lung Injury Anesth. Analg., June 1, 2002; 94(6): 1570 - 1576. [Abstract] [Full Text] [PDF]

				A. R. FRANZ, C. MACK, J. REICHART, F. POHLANDT, and H. D. HUMMLER Preserved Spontaneous Breathing Improves Cardiac Output during Partial Liquid Ventilation Am. J. Respir. Crit. Care Med., July 1, 2001; 164(1): 36 - 42. [Abstract] [Full Text] [PDF]

				C. PUTENSEN, S. ZECH, H. WRIGGE, J. ZINSERLING, F. STUBER, T. VON SPIEGEL, and N. MUTZ Long-Term Effects of Spontaneous Breathing During Ventilatory Support in Patients with Acute Lung Injury Am. J. Respir. Crit. Care Med., July 1, 2001; 164(1): 43 - 49. [Abstract] [Full Text] [PDF]

				P. Neumann and G. Hedenstierna Ventilatory Support by Continuous Positive Airway Pressure Breathing Improves Gas Exchange as Compared with Partial Ventilatory Support with Airway Pressure Release Ventilation Anesth. Analg., April 1, 2001; 92(4): 950 - 958. [Abstract] [Full Text] [PDF]

				J. B. Zwischenberger, S. K. Alpard, and A. Bidani Severe respiratory failure Ann. Thorac. Surg., January 1, 2001; 71(1): 394 - 396. [Full Text] [PDF]

				Z.-H. ZHOU, B. SUN, K. LIN, and L.-W. ZHU Prevention of Rabbit Acute Lung Injury by Surfactant, Inhaled Nitric Oxide, and Pressure Support Ventilation Am. J. Respir. Crit. Care Med., February 1, 2000; 161(2): 581 - 588. [Abstract] [Full Text]