Ten golden rules for individualized mechanical ventilation in acute
respiratory distress syndrome
Acute respiratory distress syndrome can be classified and diagnosed using ten rules, of which stand out:
Classification of severity
ARDS is characterized by being an inflammatory lung lesion that produces hardening and consolidation of the parenchyma, alveolar closure, alteration of vascular permeability, increased water content in the lungs and, finally, severe insufficiency of gas exchange of acute onset. Where 4 criteria are considered for the diagnosis:
Acute onset of hypoxemia, with respiratory symptoms
Presence of bilateral opacities on chest images
Absence of heart failure and / or fluid overload
Certain degree of hypoxemia, evaluated by measuring the partial pressure of oxygen (PaO 2) and the fraction of inspired oxygen (FiO 2) ratio
Tidal volume(VT), plateau pressure(Pplat), and
driving pressure(đťš«P)
They wanted to maintain the partial pressure of carbon dioxide (PaCo2), leaving it as close to the normal range as a result, resulting in a much higher respiratory rate.
They wanted to maintain the partial pressure of carbon dioxide (PaCo2), leaving it as close to the normal range as a result, resulting in a much higher respiratory rate.
When talking about hypercapnia, it can be established that:
it induces the release of catecholamines
Increases pulmonary vascular resistance
Suppresses inflammation and the production of free radicals
Where it is established that the use of a heated humidifier can control hypercapnia, although in the case of marked hypercapnia the tidal volume can be increased above 6ml
PEEP
It can be said that for the treatment of ARDS it is considered essential due to:
Generates alveolar recruitment
And Reduction of intrapulmonary bypass and arterial oxygenation
If we talk about the harmful effects, it can be said that:
There is an increase in lung volume at the end of inspiration
Elevated risks of volutrauma and ventilator-induced lung injury
As an analysis, it was taken into account that:
Patients with ARDS who showed an improvement in oxygenation with a high PEEP were established to have a lower risk of mortality.
It compares:
Low PEEP
High PEEP
Improve survival
It is associated with lower mortality in patients with moderate and severe ARDS and higher mortality in those with mild ARDS
Achieve a minimum acceptable oxygen saturation
Recruitment maneuvers(RMs)
In the case of ARDS, it causes the total weight of the lungs to increase this due to the interstitial and alveolar edema
In the case of alveolar collapse
Reduces the total lung surface area available for gas exchange
Promotes lung injury by increasing shear stress in areas located at the interface between aerated and collapsed alveoli
Decrease intrapulmonary bypass and improve oxygenation and compliance
Neuromuscular blocking agents(NMBA4)
Inhibit active breathing in patients
Increase compliance, functional residual capacity
Regional distribution of tidal volume
They reduce patient-ventilator asynchronies and oxygen consumption
as a long-term side effect it was established:
Muscle weakness
Specifically, neuromuscular blocking agents do not reduce the risk of mortality at 28 and 90 days, without a ventilator or the duration of mechanical ventilation, but they improve oxygenation and reduce barotrauma without affecting ICU weakness.
Assisted ventilation
In addition to generating an intense respiratory effort, due to an exaggerated respiratory impulse
Spontaneous breathing can increase the inflammatory response and lung injury from the ventilator.
Prone positioning
Achieves a more homogeneous ventilation / perfusion ratio and, consequently, intrapulmonary bypass is reduced
Improves oxygenation
Reduces the risk of ventilator-induced lung injury
Leads to redistribution of perfusion rather than recruitment
Increases regional ventilation and survival
It is the best technique for opening the lungs and keeping them open, but with minimal acceptable airway pressure and oxygenation and lower PEEP
ECMO
Provide too much flow for minimal oxygenation and CO 2 removal (which requires low blood flow)
Guidelines for its start:
PaCO 2 retention despite maximum mechanical ventilation settings
Severe air leak syndrome
Reduce the risk of ventilator-induced lung injury by adopting an ultra-protective ventilation strategy
Hypoxic respiratory failure
Based on this, the progress obtained based on the treatment of ARDS was established, taking into account specific criteria based on mechanical ventilation and its management.