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Correction methods for acute respiratory failure in acute lung injury / acute respiratory distress syndrome with a proven effect on mortality and fan-induced lung damage

• ???? Ventilation with small tidal volumes. The use of small tidal volumes can reduce the manifestations of volumotrauma and avoid high transpulmonary pressures. According to the largest multicenter randomized controlled trial conducted by ARDSnet in 41 centers and including 861 patients, the use of small tidal volumes (6 ml / kg body weight) leads to a decrease in mortality in acute respiratory infections / ARDS by 8.8% (decrease in relative mortality by 22%) . This is the only study among analogues in which there were statistically significant differences in the values ​​of tidal volumes and plateau pressures among groups using confidence intervals. In addition, the number of randomized patients in this study significantly exceeds the amount of patients in other similar studies. The use of respiratory volumes of 6 ml / kg of body weight in patients with ARF / ARDS is recommended.

• ???? Application of optimal PEEP. The optimal PEEP is one of the most important factors in protecting the lungs from ventilator-induced lung damage (atelectatic injury) and in ensuring oxygenation of arterial blood by keeping the alveoli “open”. It has been empirically proven that the use of PDKV for PLD / ARDS is less than 10 cm aq. Art. leads to an increase in mortality. The values ​​of optimal PEEP during ARF / ARDS are mainly in the range of 10-15 cm aq. Art.

• ???? Using alveoli recruitment maneuvers. Alveolar recruitment maneuver is a therapeutic technique aimed at straightening partially collabied (potentially recruited, “unstable”) alveoli. According to multicenter randomized controlled trials using computed tomography, recruiting alveoli can significantly increase the number of functioning alveoli, increase the respiratory index and reduce the shunt fraction (“open” the lungs). The use of recruitment maneuvers is carried out at an early stage of ARDS (before the development of fibro-proliferation), and patients with extrapulmonary ARDS respond better to maneuver than patients with primary lung damage. The recruitment maneuver can be performed both in the supine position and in the supine position (more efficiently). Before starting the maneuver, the patient is injected with a sedative and muscle relaxant and an analysis of the gas composition of arterial blood is performed. The maneuver is carried out by creating a constantly positive pressure (CPAP, Pinsp) in 40 cm aq. Art. for 30-40 seconds, followed by a return to the established respiratory support parameters and the selection of the optimal PEEP to prevent re-collapse of the alveoli, which is the maneuver being monitored by blood pressure, heart rate, SpO2. After the maneuver, a second analysis of arterial blood gases is performed. If there is no effect, the maneuver can be repeated. Given the possibility of "re-recruiting" of the alveoli, it is often necessary to reuse the maneuver after a few hours.

• ???? Protective ventilation of the lungs. The combination of small tidal volumes, alveolar recruitment maneuvers and optimal PEEP due to the sparing effect on the lung parenchyma is called protective lung ventilation. This methodology leads to a decrease in ventilator-induced lung damage during ARS / ARDS (barotrauma, volumotrauma, atelectatic trauma and biotrauma), a decrease in transpulmonary pressure and plateau pressure, in the absence of increased cytokines in blood plasma and a decrease in mortality in ARS / ARDS.

• ???? Ventilation in the supine position. Ventilation of the lungs while lying on the stomach leads to the involvement of non-functioning alveoli in the gas exchange (recruitment), an increase in the functional residual capacity of the lungs, an improvement in ventilation-perfusion ratios, a decrease in fan-induced lung damage, and an improvement in the drainage function of the lungs. According to the data of randomized multicenter studies, a significant decrease in mortality was found when applying lung ventilation while lying on the stomach with an extremely severe course of respiratory distress syndrome, which amounted to 24% in the subgroup with the initial respiratory index of less than 88 mm Hg. Art. and 30% in the subgroup with an initial SAPS II score of more than 49 points. The use of this maneuver is recommended for all patients who do not have contraindications to the supine position (skeletal traction, laparotomy). In extremely severe cases of distress syndrome a, extrapulmonary distress syndrome, the use of ventilation in the supine position is the method of choice.

Correction methods for acute respiratory failure in acute lung injury / acute respiratory distress syndrome with an unproven effect on mortality

• ???? High-frequency ventilation of the lungs. According to the methodology, high-frequency lung ventilation is a type of protective lung ventilation, because very small tidal volumes are used, a high auto-PDKV is created, there is practically no increase in cytokines in blood plasma. However, there are no evidence-based studies on the use of HF mechanical ventilation in patients with ARF / ARDS, therefore, the assessment of the effectiveness and safety of HF mechanical ventilation for ARF / ARDS is evaluated by doctors in each case. There are no recommendations on the use of the technique in patients with ARF / ARDS.

• ???? Ventilation of the lungs with an inverse ratio of inspiration to expiration and permissible hypercapnia. Ventilation of the lungs with an inverse ratio of inspiration to exhalation leads to a decrease in shunt and improved oxygenation of arterial blood in patients with ARF / ARDS, mainly due to the creation of high PDKV auto. No differences were found in the studies when applying the optimal PDKV setting and the non-inverted inspiratory to expiratory ratio compared to auto-PDKV and the inverse inspiratory to expiratory ratio. But the inverse ratio of inhalation to expiration is less comfortable for the patient, requires deep sedation and myoplegia with the risk of complications arising from this, and auto-PEEP inhibits hemodynamics to a greater extent than external PEEP. The permissible hypercapnia that occurs during such ventilation regimes can lead to adverse neurological consequences.
The positive effects of permissible hypercapnia with mechanical ventilation have not been studied enough, although some authors believe that hypercapnia itself is a protective factor in ARF / ARDS, leading to a decrease in lung cytokine production. Given the inhibition of hemodynamics and the deterioration in the distribution of ventilation / perfusion with deep sedation, ventilation with an inverse ratio of inspiration to expiration cannot be recommended as the treatment of choice for ARF / ARDS in severe sepsis. The question of the use of permissible hypercapnia should be decided individually. Indications for the use of this technique should be strictly limited, if possible, it is necessary to reduce the time of hypercapnia, it is necessary to carefully monitor the neurological status and carry out deep drug sedation. Absolute contraindications are the acute period of severe head injury, decompensated brain disease with the development of cerebral edema (cerebral infarction, cerebral hemorrhage, brain tumor, episindrome).

• ???? Inhalation use of nitric oxide (II). Randomized multicenter controlled trials of the use of inhaled nitric oxide (II) in patients with ARF / ARDS showed improved oxygenation in all groups of patients and improved survival in some groups of patients (inspiratory fraction NO 5 ppm). However, in these studies, the number of patients with sepsis causing lung damage was small. Inhalation therapy with nitric oxide (II) can be recommended as reserve therapy in patients with ARDS.

• ???? Extracorporeal membrane oxygenation. In a number of uncontrolled studies, data were obtained on improving oxygenation and survival among patients with extremely severe acute respiratory distress syndrome (an average score on the Murray scale of more than 3 points and an average respiratory index of less than 70 mm Hg). Controlled studies on the application of this technique have not been conducted. Extracorporeal membrane oxygenation can be recommended as reserve therapy in patients with extremely severe ARDS.

• ???? Non-invasive ventilation. It is possible to use non-invasive ventilation in patients with ARDS under the following conditions: a clear consciousness of the patient, patient's cooperation with the staff, the absence of trauma to the facial skeleton, clinical sepsis or PON.

Damaging factors in mechanical ventilation: pulmonary damage factors proven by now (“mechanical factors of mechanical ventilation”) are:

• ???? tidal volume of more than 10 ml / kg;

• ???? inspiratory fraction of oxygen more than 0.6;

• ???? inverted inspiratory to expiratory ratio;

• ???? inadequate PEEP.

Ventilation Adequacy Criteria:

Criteria for initiating respiratory support in ARDS:

• ???? absolute:

- lack of independent breathing and pathological breathing rhythms;

- violation of patency of the upper respiratory tract;

- shock of any genesis;

- hemodynamic disorders (life-threatening rhythm disturbances, persistent tachycardia of more than 120 per minute, hypotension);

• ???? relative (a combination of 2 or more factors is an indication to the beginning of respiratory support):

- a decrease in the respiratory index of less than 300 mm RT. Art. when combined with other criteria;

- development of encephalopathy and cerebral edema with oppression of consciousness and impaired FVD;

- hypercapnia or severe hypocapnia;

- tachypnea of ​​more than 40 per minute (or 24 with exacerbation of chronic obstructive pulmonary disease) and a progressive increase in the minute volume of ventilation;

- decrease in VC less than 10 ml / kg of body weight;

- a progressive decrease in compliance;

- an increase in airway resistance of more than 15 cm aq. st / l / s;

- patient fatigue, involvement of auxiliary respiratory muscles.

Criteria for starting withdrawal of respiratory support:

• ???? clear consciousness, the absence of neurological signs of cerebral edema (for example, you can wean patients in a vegetative state) and pathological breathing rhythms;

• ???? positive dynamics of infiltrates on the chest radiograph;

• ???? the stability of hemodynamics and the absence of life-threatening rhythm disturbances at a dopamine (dobutamine) injection rate of less than 5 mcg / kg / min, mesatone in any dosage;

• ???? increasing statistical compliance;

• ???? airway resistance less than 10 cm aq. st / l / s;

• ???? the absence of violations of the acidic ground state;

• ???? Tobin index (f / Vt) less than 105;

• ???? fever <38 ° C;

• ???? the absence of pronounced manifestations of DIC-syndrome (clinically significant bleeding or hypercoagulation).

At the same time, respiratory support is reduced in stages, at each stage there should be:

• ???? decrease in the inspiratory fraction of oxygen (initial FiO2 <0.4);

• ???? gradual reduction of hardware breaths to zero (if they were set) with the installation of a support pressure equal to the pressure of the plateau of a hardware breath;

• ???? gradual decrease in the level of inspiratory pressure under the control of the Tobin index (f / Vt should be less than 105) to 4 cm aq. Art. (in the presence of an endotracheal tube) or to zero (with a tracheostomy tube);

• ???? gradual decrease in PEEP / CPAP at 1-2 cm aq. Art. to zero level.

Transferring the patient to fully independent breathing is possible when the minimum level of respiratory support is achieved (FiO2 less than 0.3, PEEP less than 5 cm water column, inspiratory pressure less than 4 cm water column from the maximum concentration limit, Tobin index less than 105) and criteria are met adequate lung ventilation.

The main causes of failure when weaning from a respirator:

• ???? continuing respiratory distress syndrome (for example, severe fibro-proliferative stage of ARDS);

• ???? neurological causes (pathological respiratory rhythms, polyneuropathy);

• ???? patient malnutrition (depletion of protein and energy reserves);

• ???? atrophy of the respiratory muscles.
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Correction methods for acute respiratory failure in acute lung injury / acute respiratory distress syndrome with a proven effect on mortality and fan-induced lung damage

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