title: Pressure-controlled, inverse ratio ventilation that avoids air trapping in the adult respiratory distress syndrome.
abstract: OBJECTIVE
  To investigate physiologic and outcome data in patients switched from volume-cycled conventional ratio ventilation to pressure-controlled inverse ratio ventilation that did not produce air trapping and intrinsic positive end-expiratory pressure (PEEP).
  
  
  METHODS
  Medical intensive care unit.
  
  
  METHODS
  Retrospective analysis of crossover data and outcome.
  
  
  METHODS
  Fourteen patients with the adult respiratory distress syndrome who were receiving mechanical ventilation with volume-cycled, conventional ratio ventilation followed by pressure-controlled, inverse ratio ventilation.
  
  
  METHODS
  Our approach to pressure-controlled, inverse ratio ventilation was to use tidal volumes and applied PEEP values comparable to those volumes and values used on volume-cycled, conventional ratio ventilation, use inspiratory times to increase mean airway pressure instead of additional applied PEEP, and avoid air trapping (intrinsic PEEP).
  
  
  RESULTS
  With this approach, there was a reduction in peak airway pressure from 53 +/- 8.5 (SD) to 40 +/- 5.9 cm H2O (p < .01), and an increase in mean airway pressure from 20 +/- 3.9 to 30 +/- 5.2 cm H2O (p < .01). Tidal volume, mean inflation pressure, and compliance did not change. Oxygenation (PaO2) improved from 57 +/- 11.3 torr (7.6 +/- 1.5 kPa) to 94 +/- 40.2 torr (12.5 +/- 5.4 kPa) (p = .01) but the oxygenation index (mean airway pressure x FIO2 x 100/PaO2) did not change significantly (25.9 +/- 10.3 to 27.2 +/- 12.2). There was no significant change in PaCO2 or pH even though delivered minute ventilation decreased from 17.4 +/- 4.3 to 14.8 +/- 5.8 L/min (p = .02). Cardiac index slightly decreased, but hemodynamic values were otherwise stable. Only three of the 14 study patients survived.
  
  
  CONCLUSIONS
  These data demonstrate that oxygenation is primarily a function of mean airway pressure, and that longer inspiratory times can be used as an alternative to applied PEEP to increase this oxygenation. If no air trapping develops, lung inflation pressures and delivered volumes remain constant with this approach. Because the technique was used only in patients refractory to conventional techniques, the poor outcome is not surprising.
authors.affiliation: Division of Cardiac Surgery, Scripps Clinic and Research Foundation, La Jolla, CA.
authors.forename: B W
authors.initials: BW
authors.lastname: Armstrong
authors.forename: N R
authors.initials: NR
authors.lastname: MacIntyre
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010100:Oxygen / Q000097:blood; D011175:Positive-Pressure Respiration / Q000009:adverse effects / Q000379:methods*; D018467:Positive-Pressure Respiration, Intrinsic / Q000517:prevention & control; D012121:Respiration, Artificial; D012128:Respiratory Distress Syndrome / Q000097:blood / Q000503:physiopathology / Q000628:therapy*; D012189:Retrospective Studies
chemical_list: D010100:Oxygen