Top

Intensive Care Medicine

Published in:

01-03-2007 | Original

Is there a safe plateau pressure in ARDS? The right heart only knows

Authors: François Jardin, Antoine Vieillard-Baron

Published in: Intensive Care Medicine | Issue 3/2007

Abstract

Objective

Airway pressure limitation is now a largely accepted strategy in adult respiratory distress syndrome (ARDS) patients; however, some debate persists about the exact level of plateau pressure which can be safely used. The objective of the present study was to examine if the echocardiographic evaluation of right ventricular function performed in ARDS may help to answer to this question.

Design and patients

For more than 20 years, we have regularly monitored right ventricular function by echocardiography in ARDS patients, during two different periods, a first (1980–1992) where airway pressure was not limited, and a second (1993–2006) where airway pressure was limited. By pooling our data, we can observe the effect of a large range of plateau pressure upon mortality rate and incidence of acute cor pulmonale.

Results

In this whole group of 352 ARDS patients, mortality rate and incidence of cor pulmonale were 80 and 56%, respectively, when plateau pressure was > 35 cmH₂O; 42 and 32%, respectively, when plateau pressure was between 27 and 35 cmH₂O; and 30 and 13%, respectively, when plateau pressure was < 27 cmH₂O. Moreover, a clear interaction between plateau pressure and cor pulmonale was evidenced: whereas the odd ratio of dying for an increase in plateau pressure from 18–26 to 27–35 cm H₂O in patients without cor pulmonale was 1.05 (p = 0.635), it was 3.32 in patients with cor pulmonale (p < 0.034).

Conclusion

We hypothesize that monitoring of right ventricular function by echocardiography at bedside might help to control the safety of plateau pressure used in ARDS.

Mead J, Takishima T, Leith D (1970) Stress distribution in lungs: a model of pulmonary elasticity. J Appl Physiol 28:596–608PubMed

Webb H, Tierney D (1974) Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressure. Protection by positive end-expiratory pressure. Am Rev Respir D 110:556–565

Dreyfuss D, Basset G, Soler P, Saumon G (1985) Intermittent positive-pressure hyperventilation with high inflation pressures produces pulmonary microvascular injury in rats. Am Rev Respir D 132:880–884

Hickling K, Henderson S, Jackson R (1990) Low mortality associated with low volume/pressure limited ventilation with permissive hypercapnia in severe adult respiratory distress syndrome. Intensive Care Med 16:372–377PubMedCrossRef

Whittenberger J, McGregor M, Berglund E, Borst H (1960) Influence of state of inflation of the lung on pulmonary vascular resistance. J Appl Physiol 15:878–882PubMed

Morgan B, Martin W, Hornbein T, Crowford E, Guntheroth W (1966) Hemodynamic effects of intermittent positive pressure respiration. Anesthesiology 27:584–590PubMedCrossRef

Howell J, Permutt S, Proctor D, Riley R (1961) Effect of inflation of the lung on different parts of the pulmonary vascular bed. J Appl Physiol 16:71–76PubMed

Zapol W, Snider M (1977) Pulmonary hypertension in severe acute respiratory failure. N Engl J Med 296:476–480PubMedCrossRef

Jardin F, Gurdjian F, Fouilladieu JL, Goudot B, Margairaz A (1979) Pulmonary and systemic hemodynamic disorders in adult respiratory distress syndrome. Intensive Care Med 5:127–133PubMedCrossRef

10.

Jardin F, Gueret P, Dubourg O, Farcot JC, Margairaz A, Bourdarias JP (1985) Two-dimensional echocardiographic evaluation of right ventricular size and contractility in acute respiratory failure. Crit Care Med 13:952–956PubMedCrossRef

11.

Jardin F, Dubourg O, Bourdarias JP (1997) Echocardiographic pattern of acute cor pulmonale. Chest 111:209–217PubMed

12.

Squara P, Dhainaut JF, Artigas A, Carlet J and the European Collaborative ARDS Working Group (1998) Hemodynamic profile in severe ARDS: results of the European Collaborative ARDS Study. Intensive Care Med 24:1018–1028PubMedCrossRef

13.

Monchi M, Bellenfant F, Cariou A, Joly JM, Thebert D, Laurent I, Dhainaut JF, Brunet F (1998) Early predictive factors of survival in the acute respiratory distress syndrome. A multivariate analysis. Am J Respir Crit Care Med 158:1076–1081PubMed

14.

Slutsky A (1993) Mechanical ventilation. American College of Chest Physicians' Consensus Conference. Chest 104:1833–1859PubMed

15.

Esteban A, Anzueto A, Frutos F, Alia I, Brochard L, Stewart T, Benito S, Epstein S, Apezteguia C, Nightingale P, Arroliga A, Tobin M (2002) Characteristics and outcomes in adult patients receiving mechanical ventilation. A 28-Day International study. J Am Med Assoc 287:345–355CrossRef

16.

Hager D, Krishnan J, Hayden D, Bower R (2005) Tidal volume reduction in patients with acute lung injury when plateau pressure are not high. Am J Respir Crit Care Med 172:1241–1245PubMedCrossRef

17.

Ferguson N, Frutos-Vivar F, Esteban A, Anzueto A, Alia I, Bower G, Stewart T, Apezteguia C, Gonzales M, Soto L, Abroug F, Brochard L (2005) Airway pressure, tidal volume, and mortality in patients with acute respiratory distress syndrome. Crit Care Med 33:21–30PubMedCrossRef

18.

Eichacker P, Gerstenberger E, Banks S, Xizhong C, Natanson S (2002) Meta-analysis of acute lung injury and acute respiratory distress syndrome trials testing low tidal volumes. Am J Respir Crit Med 166:1510–1514CrossRef

19.

Page B, Vieillard-Baron A, Beauchet A, Aegerter P, Prin S, Jardin F (2003) Low stretch ventilation strategy in acute respiratory distress syndrome: eight years of clinical experience in a single center. Crit Care Med 31:765–769PubMedCrossRef

20.

Vieillard-Baron A, Schmitt JM, Beauchet A, Augarde R, Prin S, Page B, Jardin F (2001) Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: incidence, clinical implications and prognosis. Crit Care Med 29:1551–1555PubMedCrossRef

21.

The Acute Respiratory Distress Syndrome Network (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301–1308CrossRef

22.

Deans K, Minneci P, Cui X, Banks S, Natanson C, Eichaker P (2005) Mechanical ventilation in ARDS: one size does not fit all. Crit Care Med 33:1141–1144PubMedCrossRef

23.

Gattinoni L, Pesanti A (2005) The concept of “baby lung”. Intensive Care Med 31:776–784PubMedCrossRef

Title: Is there a safe plateau pressure in ARDS? The right heart only knows
Authors: François Jardin
Antoine Vieillard-Baron
Publication date: 01-03-2007
Publisher: Springer-Verlag
Published in: Intensive Care Medicine / Issue 3/2007
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-007-0552-z

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Is there a safe plateau pressure in ARDS? The right heart only knows

Abstract

Objective

Design and patients

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Objective

Design and patients

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 3/2007

Increasing evidence that the risks of rhAPC may outweigh its benefits

Shock during heparin-induced thrombocytopenia: Look for adrenal insufficiency!

Evaluating the use of Drotrecogin alfa (activated) in adult severe sepsis: a Canadian multicenter observational study

Sedation assessment tool, sedation-algorithm, choice of sedation drugs: intricate concepts of an emergent clinical practice

Effect of ornithine α-ketoglutarate on glutamine pools in burn injury: evidence of component interaction

The “Lund concept”: what it is and what it isn't