Colesterol e cardiopatias

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Mechanical Ventilation in ARDS*
A State-of-the-Art Review
Timothy D. Girard, MD; and Gordon R. Bernard, MD, FCCP
Mechanical ventilation is an essential component of the care of patients with ARDS, and a large
number of randomized controlled clinical trials have now been conducted evaluating the efficacy
and safety of various methods of mechanical ventilation for the treatment of ARDS. Lowtidal
volume ventilation (< 6 mL/kg predicted body weight) should be utilized in all patients with
ARDS as it is the only method of mechanical ventilation that, to date, has been shown to improve
survival. High positive end-expiratory pressure, alveolar recruitment maneuvers, and prone
positioning may each be useful as rescue therapy in a patient with severe hypoxemia, but these
methods ofventilation do not improve survival for the wide population of patients with ARDS.
Although not specific to the treatment of ARDS, protocol-driven weaning that utilizes a daily
spontaneous breathing trial and ventilation in the semirecumbent position have proven benefits
and should be used in the management of ARDS patients. (CHEST 2007; 131:921–929)
Key words: acute lung injury; ARDS; mechanicalventilation; positive end-expiratory pressure; prone position; tidal
Abbreviations: ALI  acute lung injury; ALVEOLI  Assessment of Low Tidal Volume and Elevated End-Expiratory
Pressure To Obviate Lung Injury; APACHE  acute physiology and chronic health evaluation; APRV  airway pressure
release ventilation; ARMA  Respiratory Management in Acute Lung Injury/Acute RespiratoryDistress Syndrome;
CI  confidence interval; Fio2  fraction of inspired oxygen; IL  interleukin; IRV  inverse ratio ventilation;
PEEP  positive end-expiratory pressure; Pflex  lower inflection point on the pressure-volume curve of the
respiratory system
Prior to the development and widespread use of
positive-pressure ventilators, acute lung injury
(ALI) and ARDS, often termed double pneumonia,were nearly universally fatal forms of respiratory
failure. However, in 1967 when Ashbaugh and colleagues1
described the clinical entity that they called
“acute respiratory distress in adults,” positive-pressure
mechanical ventilation was an important component
of the care of patients with acute respiratory
failure, and it was clear that this therapy was vital to
the survival of patientswith ARDS. Over the next 3
decades, general improvements in critical care contributed
to some decline in the mortality associated
with ARDS, but these benefits reached a plateau by
the 1990s.2
Later that decade, the first randomized trials were
conducted showing that an experimental method of
mechanical ventilation (low tidal volume ventilation)
could reduce mortality compared withtraditional
methods of ventilation. This article will review these
and other clinical trials and make recommendations
regarding the use of mechanical ventilation in the
treatment of ARDS patients.
Low Tidal Volume Ventilation
Early interest in low tidal volume ventilation was
prompted by animal studies3,4 showing that ventilation
with large tidal volumes and high inspiratory
*From the Divisionof Allergy, Pulmonary, and Critical Care
Medicine, Vanderbilt University School of Medicine, Nashville,
The authors have reported to the ACCP that no significant
conflicts of interest exist with any companies/organizations whose
products or services may be discussed in this article.
Manuscript received June 15, 2006; revision accepted September
13, 2006.
Reproduction of this article isprohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
Correspondence to: Timothy D. Girard, MD, 6th Floor MCE,
Suite 6100, Center for Health Services Research, Vanderbilt
University School of Medicine, Nashville, TN 37232-8300; e-mail:
DOI: 10.1378/chest.06-1515
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