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Abstract
PurposeThe efficacy of partial ventilatory support modes that allow spontaneous breathing in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) is unclear. The objective of this scoping review was to assess the effects of partial ventilatory support on mortality, duration of mechanical ventilation, and both hospital and intensive care unit (ICU) lengths of stay (LOS) for patients with ALI and ARDS; the secondary objective was to describe physiologic effects on hemodynamics, respiratory system and other organ function.MethodsMEDLINE (1966–2009), Cochrane, and EmBase (1980–2009) databases were searched using common ventilator modes as keywords and reference lists from retrieved manuscripts hand searched for additional studies. Two researchers independently reviewed and graded the studies using a modified Oxford Centre for Evidence-Based Medicine grading system. Studies in adult ALI/ARDS patients were included for primary objectives and pre-clinical studies for supporting evidence.ResultsTwo randomized controlled trials (RCTs) were identified, in addition to six prospective cohort studies, one retrospective cohort study, one case control study, 41 clinical physiologic studies and 28 pre-clinical studies. No study was powered to assess mortality, one RCT showed shorter ICU length of stay, and the other demonstrated more ventilator free days. Beneficial effects of preserved spontaneous breathing were mainly physiological effects demonstrated as improvement of gas exchange, hemodynamics and non-pulmonary organ perfusion and function.ConclusionsThe use of partial ventilatory support modalities is often feasible in patients with ALI/ARDS, and may be associated with short-term physiological benefits without appreciable impact on clinically important outcomes.
Highlights
Rationale Mechanical ventilation restores gas exchange in patients with respiratory failure
Recent trials of patients with acute respiratory distress syndrome (ARDS) suggest that upward of 30% of patients are paralyzed with neuromuscular blockers and managed with controlled modes of ventilation during the acute phase of respiratory failure [2,3]
Wherein the degree of mechanical support provided is adjusted to patient need, preserves diaphragmatic contraction and allows spontaneous breathing efforts
Summary
Rationale Mechanical ventilation restores gas exchange in patients with respiratory failure. In patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), controlled modes of mechanical ventilation that deliver full ventilatory support have traditionally been used to completely offload the work of breathing and thereby ‘‘rest the lung’’ and diaphragm [1]. The ventilator performs the entire work of breathing and patients are generally sedated, and/or chemically paralyzed, prohibiting spontaneous breathing efforts. Reserved for use in weaning patients from mechanical ventilation [4], partial ventilatory support modes are used in all phases of ventilation [5]. Partial ventilatory support has been investigated in both animals and humans during the acute phases of lung injury, uncertainty remains as to whether or not its use is beneficial or even feasible in patients with ALI and ARDS
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