Ventilation in patients with intra-abdominal hypertension: what every critical care physician needs to know

Adrian Regli; Paolo Pelosi; Manu L. N. G. Malbrain

doi:10.1186/s13613-019-0522-y

Annals of Intensive Care

Table 3 Suggested ventilation strategies depending on the presence of ARDS and IAH

From: Ventilation in patients with intra-abdominal hypertension: what every critical care physician needs to know

	Normal	ARDS	IAH	IAH and respiratory failure
Tidal volume	6 to 8 mL/kg PBW may be beneficial	Recommended 4–8 mL/kg PBW (Grade 1B) [123, 124]	6 to 8 mL/kg PBW may be beneficial	4–8 mL/kg PBW may be beneficial
Inspiratory plateau pressure	< 20 cmH₂O	Recommended < 30 cmH₂O to reduce risk of alveolar over-distension (Grade 1B) [123]	Higher airway pressures may be acceptable and may arise due to reduced chest wall compliance. Corrected target plateau pressure = target plateau pressure − 7 + IAP (mmHg) * 0.7	Higher airway pressures may be acceptable and may arise due to reduced chest wall compliance. Corrected target plateau pressure = target plateau pressure − 7 + (mmHg) * 0.7
Driving pressure	< 14 cmH₂O	< 14 cmH₂O (Grade 2B) [84]	< 14 cmH₂O	< 14 cmH₂O
Inspiratory plateau trans-pulmonary pressure	< 15 cmH₂O is reasonable	< 25 cmH₂O is reasonable [29]	< 25 cmH₂O is reasonable	< 25 cmH₂O may be a reasonable target
PEEP	5 in cmH₂O	Higher PEEP levels in moderate to severe ARDS improves survival rate (Grade 2B) [123]. We suggest 5–10 cmH₂O in mild to moderate ARDS and 10–15 in moderate to severe ARDS	Higher PEEP levels may reduce atelectasis and atelectrauma. We suggest not to exceed 15 cmH₂O	Higher than usual PEEP levels may be required to improve oxygenation and respiratory mechanics. We suggest not to exceed 15 cmH₂O
PEEP titration	We suggest avoidance of excessive driving pressure	Optimal respiratory compliance, i.e. lowest driving pressure during constant protective tidal volume. Oesophageal pressure guided is a reasonable alternative	Optimal respiratory compliance, i.e. lowest driving pressure during constant protective tidal volume. We suggest PEEP in cmH₂O = IAP in mmHg	Optimal respiratory compliance, i.e. lowest driving pressure during constant protective tidal volume. Oesophageal pressure guided is a reasonable alternative
Recruitment manoeuvre (RM)	RM not routinely recommended	RM improves oxygenation, but outcome may be worsened with RM. Best RM method is unknown [65, 123]	RM not routinely recommended	Higher airway pressures might be required for RM to be effective
Prone	Not recommended	Recommended as it improves oxygenation and survival rate in patients with ARDS (Grade 1B) [108, 123]	Not recommended	May reduce IAP and improve oxygenation Important to assure free hanging abdomen and absent IAP increase [29]
NMBA	Not recommended	Short term NMBA may be beneficial [125]	May reduce IAP [121]	May reduce IAP and/or improve oxygenation
Adjunctive therapy		Nitric oxide	Negative fluid balance	Negative fluid balance
		ECCO₂R	Ascites drainage	Ascites drainage
		ECMO	Laparostoma [26, 121]	Laparostoma
				Nitric oxide, ECCO₂R, ECMO

ARDS acute respiratory distress syndrome, ECCO2R extracorporeal CO₂ removal, ECMO extracorporeal membrane oxygenation, IAH intra-abdominal hypertension, IAP intra-abdominal pressure, PBW predicted body weight, PEEP positive end-expiratory pressure, RM recruitment manoeuvre

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