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    Prevention and treatment of acute lung injury with time-controlled adaptive ventilation: physiologically informed modification of airway pressure release ventilation

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    Author
    Nieman, G.F.
    Andrews, P.
    Madden, M.
    Habashi, N.M.
    Date
    2020
    Journal
    Annals of Intensive Care
    Publisher
    Springer
    Type
    Article
    
    Metadata
    Show full item record
    See at
    https://doi.org/10.1186/s13613-019-0619-3
    Abstract
    Mortality in acute respiratory distress syndrome (ARDS) remains unacceptably high at approximately 39%. One of the only treatments is supportive: mechanical ventilation. However, improperly set mechanical ventilation can further increase the risk of death in patients with ARDS. Recent studies suggest that ventilation-induced lung injury (VILI) is caused by exaggerated regional lung strain, particularly in areas of alveolar instability subject to tidal recruitment/derecruitment and stress-multiplication. Thus, it is reasonable to expect that if a ventilation strategy can maintain stable lung inflation and homogeneity, regional dynamic strain would be reduced and VILI attenuated. A time-controlled adaptive ventilation (TCAV) method was developed to minimize dynamic alveolar strain by adjusting the delivered breath according to the mechanical characteristics of the lung. The goal of this review is to describe how the TCAV method impacts pathophysiology and protects lungs with, or at high risk of, acute lung injury. We present work from our group and others that identifies novel mechanisms of VILI in the alveolar microenvironment and demonstrates that the TCAV method can reduce VILI in translational animal ARDS models and mortality in surgical/trauma patients. Our TCAV method utilizes the airway pressure release ventilation (APRV) mode and is based on opening and collapsing time constants, which reflect the viscoelastic properties of the terminal airspaces. Time-controlled adaptive ventilation uses inspiratory and expiratory time to (1) gradually "nudge" alveoli and alveolar ducts open with an extended inspiratory duration and (2) prevent alveolar collapse using a brief (sub-second) expiratory duration that does not allow time for alveolar collapse. The new paradigm in TCAV is configuring each breath guided by the previous one, which achieves real-time titration of ventilator settings and minimizes instability induced tissue damage. This novel methodology changes the current approach to mechanical ventilation, from arbitrary to personalized and adaptive. The outcome of this approach is an open and stable lung with reduced regional strain and greater lung protection. Copyright 2020, The Author(s).
    Sponsors
    National Heart, Lung, and Blood Institute, NHLBI: R01 HL131143
    Keyword
    time-controlled adaptive ventilation
    Respiration, Artificial--methods
    Respiratory Distress Syndrome, Adult
    Ventilator-Induced Lung Injury--prevention & control
    Identifier to cite or link to this item
    https://www.scopus.com/inward/record.uri?eid=2-s2.0-85077356664&doi=10.1186%2fs13613-019-0619-3&partnerID=40&md5=555dd0582914094f6c55dae1a2a74eb3; http://hdl.handle.net/10713/11623
    ae974a485f413a2113503eed53cd6c53
    10.1186/s13613-019-0619-3
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