J C Richard1,2,3, S Marque4, A Gros5, M Muller6, G Prat7, G Beduneau8,9, J P Quenot10, J Dellamonica11, R Tapponnier12, E Soum13, L Bitker14,15,16, J Richecoeur17. 1. Service de Médecine Intensive Réanimation, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France. j-christophe.richard@chu-lyon.fr. 2. Université de Lyon, Université LYON I, Lyon, France. j-christophe.richard@chu-lyon.fr. 3. CREATIS INSERM 1044 CNRS 5220, Villeurbanne, France. j-christophe.richard@chu-lyon.fr. 4. Service de Réanimation Polyvalente, Centre Hospitalier Sud-Francilien, Corbeil-Essonnes, France. 5. Service de Réanimation Médico-Chirurgicale, Hôpital André Mignaud, Le Chesnay, France. 6. Service de Réanimation, Centre Hospitalier Annecy Genevois, Pringy, France. 7. Service de Réanimation Médicale, CHU de la Cavale Blanche, Brest, France. 8. Medical Intensive Care Department, University Hospital Centre Rouen, Rouen, France. 9. Inserm U 1096, Institute for Research and Innovation in Biomedicine (IRIB), Rouen University, Rouen, France. 10. Service de Réanimation Médicale, Hôpital François Mitterrand, Dijon, France. 11. Service de Réanimation Médicale, Hôpital Archet 1, Nice, France. 12. Service de Réanimation, Centre Hospitalier Lyon Sud, Pierre-Bénite, France. 13. Service de Réanimation Médicale Polyvalente, CHU Gabriel-Montpied, Clermont-Ferrand, France. 14. Service de Médecine Intensive Réanimation, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France. 15. Université de Lyon, Université LYON I, Lyon, France. 16. CREATIS INSERM 1044 CNRS 5220, Villeurbanne, France. 17. Service de Réanimation Polyvalente, Centre Hospitalier de Beauvais, Beauvais, France.
Abstract
PURPOSE: Mechanical ventilation with ultra-low tidal volume (VT) during ARDS may reduce alveolar strain, driving pressure and hence ventilator-induced lung injury, with the main drawback of worsening respiratory acidosis. We hypothesized that VT could be reduced down to 4 ml/kg, with clinically significant decrease in driving pressure, without the need for extracorporeal CO2 removal, while maintaining pH > 7.20. METHODS: We conducted a non-experimental before-and-after multicenter study on 35 ARDS patients with PaO2/FiO2 ≤ 150 mmHg, within 24 h of ARDS diagnosis. After inclusion, VT was reduced to 4 ml/kg and further adjusted to maintain pH ≥ 7.20, respiratory rate was increased up to 40 min-1 and PEEP was set using a PEEP-FiO2 table. The primary judgment criterion was driving pressure on day 2 of the study, as compared to inclusion. RESULTS: From inclusion to day 2, driving pressure decreased significantly from 12 [9-15] to 8 [6-11] cmH2O, while VT decreased from 6.0 [5.9-6.1] to 4.1 [4.0-4.7] ml/kg. On day 2, VT was below 4.2 ml/kg in 65% [CI95% 48%-79%], and below 5.25 ml/kg in 88% [CI95% 74%-95%] of the patients. 2 patients (6%) developed acute cor pulmonale after inclusion. Eleven patients (32%) developed transient severe acidosis with pH < 7.15. Fourteen patients (41%) died before day 90. CONCLUSION: Ultra-low tidal volume ventilation may be applied in approximately 2/3 of moderately severe-to-severe ARDS patients, with a 4 cmH2O median reduction in driving pressure, at the price of transient episodes of severe acidosis in approximately 1/3 of the patients.
PURPOSE: Mechanical ventilation with ultra-low tidal volume (VT) during ARDS may reduce alveolar strain, driving pressure and hence ventilator-induced lung injury, with the main drawback of worsening respiratory acidosis. We hypothesized that VT could be reduced down to 4 ml/kg, with clinically significant decrease in driving pressure, without the need for extracorporeal CO2 removal, while maintaining pH > 7.20. METHODS: We conducted a non-experimental before-and-after multicenter study on 35 ARDSpatients with PaO2/FiO2 ≤ 150 mmHg, within 24 h of ARDS diagnosis. After inclusion, VT was reduced to 4 ml/kg and further adjusted to maintain pH ≥ 7.20, respiratory rate was increased up to 40 min-1 and PEEP was set using a PEEP-FiO2 table. The primary judgment criterion was driving pressure on day 2 of the study, as compared to inclusion. RESULTS: From inclusion to day 2, driving pressure decreased significantly from 12 [9-15] to 8 [6-11] cmH2O, while VT decreased from 6.0 [5.9-6.1] to 4.1 [4.0-4.7] ml/kg. On day 2, VT was below 4.2 ml/kg in 65% [CI95% 48%-79%], and below 5.25 ml/kg in 88% [CI95% 74%-95%] of the patients. 2 patients (6%) developed acute cor pulmonale after inclusion. Eleven patients (32%) developed transient severe acidosis with pH < 7.15. Fourteen patients (41%) died before day 90. CONCLUSION: Ultra-low tidal volume ventilation may be applied in approximately 2/3 of moderately severe-to-severe ARDSpatients, with a 4 cmH2O median reduction in driving pressure, at the price of transient episodes of severe acidosis in approximately 1/3 of the patients.
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