Acute Lung Injury Clinical Trial
Official title:
Prospective Study on the Effects of Artificial Breathing Patterns on Work of Breathing in Patients With Acute Lung Injury.
The primary goal of this study is to measure changes in biological markers of inflammation
in critically-ill patients with acute lung injury (ALI) or acute respiratory distress
syndrome (ARDS) while they are treated with different styles of lung-protective, artificial
breathing assistance.
Secondary goals are to measure the breathing effort of patients using different artificial
breathing patterns from the breathing machine.
The primary hypothesis is that volume-targeted artificial patterns will produce less
inflammation. The secondary hypothesis is that volume-targeted artificial patterns will
increase breathing effort compared to pressure-targeted artificial patterns.
Ventilator-induced lung injury contributes to the progression of ALI/ARDS,1 and is thought
to occur partly from the unequal distribution of a super-normal tidal volume to normal areas
of the lung.2 Alveolar overdistension causes alveolar-capillary membrane damage,3
increased-permeability pulmonary edema4 and hyaline membrane formation.5 Therefore, it is
recommended that tidal volume should be reduced to 6-7 mL/kg, and that the peak alveolar
pressure, or the end-inspiratory plateau pressure (PPLAT), should be limited to < 30 cm
H2O.6 The National Heart Lung and Blood Institute's ARDS Network demonstrated a 22%
reduction in mortality using a "lung-protective" (low tidal volume) ventilation strategy in
patients with ALI/ARDS.7 High tidal volume ventilation causes a rapid and substantial
increase plasma levels of proinflammatory mediators which decrease in response to lung
protective ventilation.8,9 A consequence of lung-protective ventilation is dyspnea and
increased work of breathing.10 Our recent study11 on work of breathing during
lung-protective ventilation found that inspiratory pleural pressure changes were
extraordinarily high, averaging 15-17 cm H2O. Whereas tidal volume was well controlled
during volume ventilation, in contrast, it exceeded target levels in 40% of patients during
pressure control ventilation.
High tidal volume-high negative pressure ventilation causes acute lung injury in animal
models.12,13 Thus ventilator-induced lung injury results from excessive stress across lung
tissue created by high transpulmonary (airway-pleural).pressure.14 This suggests the
possibility that despite pressure control ventilation being set with a low positive airway
pressure, "occult" high tidal volume-high transpulmonary pressure ventilation still may
occur.11 However, during spontaneous breathing diaphragmatic contractions cause ventilation
to be distributed preferentially to dorsal:caudal aspects of the lungs.15 Therefore, high
transpulmonary pressures created by large negative swings in pleural pressure theoretically
may not cause regional lung over-distension and ventilator-induced lung injury if tidal
ventilation is preferentially distributed to dorsocaudal lung regions. However, a study16
examining the effects of diaphragmatic breathing during Pressure Control Ventilation found
that dorsocaudal distribution of tidal volume was not necessarily improved compared to
passive ventilation, as the amount of tidal ventilation distributed to areas of high
ventilation/perfusion was unaltered. Regardless, during a recent conference on respiratory
controversies in the critical care setting, it was noted that the effects of ventilator
modes such as volume control, pressure control and airway pressure-release ventilation on
proinflammatory cytokine expression during lung-protective ventilation has not been studied
in humans.17 Thus it is unknown whether or not differences in transpulmonary pressure and
tidal volume between these modes has a direct impact on lung inflammation.
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Allocation: Randomized, Intervention Model: Crossover Assignment, Masking: Open Label, Primary Purpose: Supportive Care
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