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Ventilation-induced pulmonary edema, lung damage, and “volume trauma” (volume trauma)

Art., depending on the type of animal.
Transcapillary mechanical forces of comparable magnitude can be created when large tidal volumes and peak static inspiratory pressure are used in the treatment of a disease accompanied by inhomogeneous lung damage.
High blood pressure and blood flow can also be important evidence of lung damage.
MANAGEMENT OF PATIENTS
There is currently no detailed clinical information regarding the safe maximum peak and average alveolar pressure values ​​that can be used for a long time without damage to the alveoli or delayed lung healing.
It is clear that the recommendations should be individual in nature (see table 8.4).
Alveolar volumes and stresses in the areas of the damaged lung are undoubtedly different (see Fig.8.6).
The impact of the total pressure applied to the endotracheal tube should be evaluated in accordance with the extensibility and vulnerability of each area of ​​the lungs.
Although the experiment showed that maintaining a certain minimum transalveolar pressure at the end of exhalation enhances the pre-existing damage to the alveoli, this phenomenon on the human body has not yet been demonstrated.
TABLE 8.5
CONTRAINDICATIONS FOR ACCEPTABLE HYPERCAPNIA
Increased intracranial pressure
Severe cardiovascular disorders
Severe pulmonary hypertension
Deep metabolic acidosis
Further, everyone agrees with the conclusion that as soon as the opening of the alveoli is achieved, a further increase in PDKV is probably useless or even harmful.
Thus, experts disagree on what to consider as the optimal treatment for the first few days of the disease: the use of the smallest PDKV, capable of ensuring adequate gas exchange, or the creation of some minimal alveolar pressure at the end of exhalation.
Some knowledgeable researchers continue to advocate for periodic use of high-pressure inflations in order to draw unstable areas of the lungs into ventilation, particularly when small tidal volumes (less than 4-5 ml / kg) are used or when high-frequency mechanical ventilation is used.
Later, during the course of the disease, PEEP should be excluded, especially if it is not possible to identify the bending region on the “volume - pressure” curve of the respiratory system.
Since elongation depends on tidal volume, the choice of the appropriate VT depends on the level of PEEP and vice versa.
There is no general opinion on the effect of vascular pressure, changes in patient position, infection, oxygen concentration in the inhaled gas, and other clinical variables on the frequency or intensity of lung damage caused by mechanical ventilation.
Raising PaCO2 to a level above normal (tolerable hypercapnia) seems to be an effective strategy for limiting inspiratory pressure (see chapter 24, “Oxygen deficiency”).
The full effect of hypercapnia on such important indicators as gas exchange, hemodynamics, and tissue edema remains to be determined in the two situations in which this strategy is commonly used - with asthma and ARDS.
In addition, there are relative and absolute contraindications for using this technique (Table 8.5).
To achieve near-complete saturation of arterial blood with oxygen, an increased FiO2 value and high inspiratory airway pressure are often required.
Conditions (if they exist) under which it is possible without severe clinical consequences to lower arterial O2 saturation to values ​​less than normal are not yet established.
There is no unanimous opinion regarding the indicator of regional or general adequacy or inadequacy (dysoxia) of O2 delivery, which is most suitable for everyday clinical use.
Such combinations of O2 concentration and duration of their use, which cause significant lung damage, have not been firmly established for ARDS and can vary depending on the severity of the condition and individual sensitivity to hypoxia.
Similarly, there is still no detailed information regarding inspiratory pressure and injection rate, which are safe for long-term use, although numerous experimental data have been accumulated.
In the absence of reliable clinical data, some experienced clinicians increase lung capacity in an effort to minimize FiO2, while others prefer not to increase peak and mean pressure and PEEP in the airways, but to use higher respirable concentrations of O2.
With F, O2 levels below 0.7, limiting Paw to a “safe” level is usually more important than limiting FiO2.
It has not yet been precisely established whether the different methods for obtaining the same average pressure in the airways (such as PDKV and ventilation with an inverted ratio of inspiration and expiration) differ in risk and benefits.
The extent to which self-ventilation has advantages over controlled ventilation is also not yet clear. (Treatment of ARDS is discussed in detail in Chapter 24, Oxygenation Disorders.)
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Ventilation-induced pulmonary edema, lung damage, and “volume trauma” (volume trauma)

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