title: The physiologic effects of inverse ratio ventilation.
abstract: OBJECTIVE
  The efficacy of inverse ratio ventilation in ARDS is not clear. Furthermore, the mechanism responsible has not been determined. We designed an animal study to determine if inverse ratio ventilation improves gas exchange and by what mechanism.
  
  
  METHODS
  Prospective randomized, controlled design was used.
  
  
  METHODS
  University of Missouri Pulmonary/Critical Care Animal Laboratory.
  
  
  METHODS
  Nine dogs with oleic acid-induced lung injury as control animals to assess stability of the model, nine in the experimental model.
  
  
  METHODS
  Conventional ventilation with full recruitment extrinsic positive end-expiratory pressure (PEEP) was compared with two other modes of ventilation. One was inverse ratio with extrinsic PEEP and the second was inverse ratio with intrinsic PEEP equal to full recruitment PEEP. Full recruitment levels of PEEP were defined by optimizing compliance, then increasing PEEP by 2.5 cm/H2O. Each type of ventilation was maintained for 45 min after the edema had stabilized. Comparison of lung injury over time requires stability of the model over time. Therefore, we also assessed the stability of the preparation over time by examining compliance, extravascular lung water, and venous admixture in nine control dogs with equivalent lung injury over the same time span.
  
  
  RESULTS
  Mean airway pressure was increased by both types of inverse ratio ventilation, while compliance remained stable. Venous admixture was reduced (conv=0.32+/-0.12, inverse ratio with extrinsic PEEP=0.24+/-0.10, inverse ratio with intrinsic PEEP=0.28+/-0.11) with inverse ratio with extrinsic PEEP, but the improvement was less with inverse ratio with intrinsic PEEP, even though the mean airway pressure was higher.
  
  
  CONCLUSIONS
  We conclude that increasing mean airway pressure by prolongation of the inspiratory time improves gas exchange in our model of ARDS, but when mean airway pressure is increased further, allowing the development of intrinsic PEEP, the beneficial effects on gas exchange are less. Increasing mean airway pressure with intrinsic PEEP is not equivalent to other methods of increasing mean airway pressure.
authors.affiliation: Department of Medicine, Pulmonary/Critical Care Medicine, University of Missouri, Columbia, USA.
authors.forename: J
authors.initials: J
authors.lastname: Yanos
authors.forename: S M
authors.initials: SM
authors.lastname: Watling
authors.forename: J
authors.initials: J
authors.lastname: Verhey
mesh_terms: D000403:Airway Resistance; D000818:Animals; D004285:Dogs; D006439:Hemodynamics; D008297:Male; D011175:Positive-Pressure Respiration; D018467:Positive-Pressure Respiration, Intrinsic; D011659:Pulmonary Gas Exchange; D011897:Random Allocation; D012121:Respiration, Artificial / Q000379:methods*; D012128:Respiratory Distress Syndrome / Q000503:physiopathology / Q000628:therapy