Tropenmedizin und Chirurgie

Abstrakt

Lung-Protective Ventilation for Adult Patients with ARDS in Intensive Care Unit: A Systematic Review and Evidence-Based Guideline

Yophtahe B Woldegerima1*, Tikuneh A Yetneberk1, Habtamu K Getinet2

Introduction: Mechanical ventilation has important role in ARDS management, despite harmful complications such as ventilator-associated lung injury (VALI). Although lung-protective ventilation (LPV) is considered to minimize VALI and improve outcomes, there are controversies on its effectiveness and ways of delivery. This article aimed to review current evidence and develop a clinical practice guideline; especially for limited human and material resource settings.

Methods: Current evidence was collected using reputable scientific search engines such as PubMed, Google Scholars, and Cochrane Library by setting appropriate filtering methods. Collected evidence was critically appraised by appropriate tools accordingly. Final conclusions and recommendations were made by comparing the benefits and downsides of the alternative strategies based on levels of evidence and classes of recommendation.

Discussion: LPV was found to decrease morbidity, mortality, hospital stay and improve long-term outcomes. It can be applied by limiting tidal volume (TV=4-7 ml/Kg), end-inspiratory plateau pressure (Pplat<30 cm H₂O), and FiO₂ and providing PEEP. Using PEEP/FiO₂ protocol designed by ARDSnet and ARMA trials is favored to date. In contrast, ventilation with both low TV and PEEP is associated with mortality. Most literature inclined to use recruitment maneuvers, but cautiously or avoid in hemodynamic instability. No mode of ventilation was found superior over the others. Oxygenation, long- term outcomes, and mortality were found to improve with early and prolonged applications of prone positioning. Neuromuscular blocking agents (NMBAs) have equivocal outcomes. They can improve oxygenation despite increased risk of ICU-acquired myopathy. However, recent studies suggested routine and early initiation of NMBAs in moderate-sever ARDS, and Cis-atracurium is the drug of choice.

Conclusion: Patients with ARDS should be treated with LPV strategy; using lower tidal volume, limited end-inspiratory plateau pressure, PEEP:FiO₂ titration protocol, recruitment maneuvers, longer prone positioning, and NMBAs. An algorithmic approach is prepared to simplify implementation.