Abstract
Mechanical ventilation practices in patients with acute respiratory distress syndrome
(ARDS) have progressed with a growing understanding of the disease pathophysiology.
Paramount to the care of affected patients is the delivery of lung-protective mechanical
ventilation which prioritizes tidal volume and plateau pressure limitation. Lung protection
can probably be further enhanced by scaling target tidal volumes to the specific respiratory
mechanics of individual patients. The best procedure for selecting optimal positive
end-expiratory pressure (PEEP) in ARDS remains uncertain; several relevant issues
must be considered when selecting PEEP, particularly lung recruitability. Noninvasive
ventilation must be used with caution in ARDS as excessively high respiratory drive
can further exacerbate lung injury; newer modes of delivery offer promising approaches
in hypoxemic respiratory failure. Airway pressure release ventilation offers an alternative
approach to maximize lung recruitment and oxygenation, but clinical trials have not
demonstrated a survival benefit of this mode over conventional ventilation strategies.
Rescue therapy with high-frequency oscillatory ventilation is an important option
in refractory hypoxemia. Despite a disappointing lack of benefit (and possible harm)
in patients with moderate or severe ARDS, possibly due to lung hyperdistention and
right ventricular dysfunction, high-frequency oscillation may improve outcome in patients
with very severe hypoxemia.
Keywords
acute respiratory distress syndrome - mechanical ventilation - positive end-expiratory
pressure - high-frequency oscillation - noninvasive ventilation - oxygen
