ALI Patients Should Be Ventilated at Lower Tidal

[Guest]

I had this in my files thought it may be informative.

New Research Suggests ALI Patients Should Be Ventilated at Lower Tidal

DES PLAINES, Ill. - Patients with acute lung injury (ALI) who were

ventilated at lower tidal volumes had a faster decrease in biological

inflammation markers than patients ventilated with higher tidal volumes,

according to an article in the January issue of Critical Care Medicine, the

journal of the Society of Critical Care Medicine. The investigators also

found that severity of inflammation varies with clinical risk factors.

"These findings lead mechanistic support to our previously published

clinical findings that low tidal volume ventilation in acute lung injury

improves morbidity and mortality," says lead investigator Polly E. Parsons,

M.D., from the division of pulmonary and critical care medicine at Fletcher

Allen Health Care, University of Vermont in Burlington. "This study further

supports the concept of reducing tidal volume to limit excessive alveolar

stretch."

ALI is associated with severe acute lung inflammation and alveolar

epithelium injury, as well as the loss of the tight permeability barrier

that restricts movement of extravascular fluid and proteins into the

airspaces. Relatively preserved alveolar epithelial function means a better

prognosis.

The researchers studied the 861 patients enrolled in the National Heart,

Lung and Blood Institute Acute Respiratory Distress Syndrome Clinical

Network trial (ARDS-NET) of lower tidal volumes (6 ml/kg) compared with

traditional tidal volumes (12 ml/kg) for ALI to evaluate the association

between IL-6, IL-8, and IL-10 and clinical outcomes. The randomized study

was set in the intensive care units of 10 university medical centers.

The investigators found that baseline plasma levels of IL-6, IL-8 and IL-10

were each associated with an increased risk of death in both logistic

regression analyses controlling for ventilator group and multivariate

analyses controlling for ventilation strategy, APACHE III score, PaO2/FIO2

ratio, creatinine, platelet count, and vasopressor use.

"IL-6 and IL-8 levels were also associated with a significant decrease in

ventilator free and organ failure free days," state the researchers.

"Patients with sepsis had the highest cytokine levels and the greatest risk

of death per cytokine elevation. By day 3, the 6-ml/kg strategy was

associated with a greater decrease in IL-6 and IL-8 levels. There was a 26%

reduction in IL-6 and a 12% reduction in IL-8 in the 6 ml/kg group compared

to the 12 ml/kg group."

Dr. Parsons notes that previous studies have found that high levels of

biologic markers of inflammation measured in the systemic circulation of

patients with acute lung injury are associated with poor outcome. "This

study confirms those observations in a large group of patients enrolled in a

multicenter clinical trial," she continues. "In addition our group has

previously shown that ventilating patients with lower tidal volumes improves

outcomes. The present study shows that in those patients ventilated with

lower tidal volumes the levels of the biologic markers of inflammation

decrease faster than in patients ventilated with higher tidal volumes."

Although translating clinical research into clinical practice can be

difficult, Dr. Parsons hopes that this study will further bolster the

evidence for the clinical practice of using lower tidal volume ventilation

in patients with acute lung injury.

Editorial: Cytokines and Lung Injury: Searching for useful biomarkers

"One of the great limitations in acute lung injury research has been the

lack of validated markers of lung injury or systemic inflammation, which can

be used to predict the severity, outcome, or response to therapy," explains

Thomas R. Martin, M.D., in an accompanying editorial.

"The report by Parsons, et al, provides a firm link between injury and

inflammation in the lungs and proves in principle that inflammatory markers

in plasma can provide useful information about the severity of illness and

the pulmonary response to a defined therapy," concludes Dr. Martin, who is

from the VA Puget Sound Medical Center in Seattle.

ALI annually affects more than 200,000 patients in the United States.

Overall mortality is estimated at approximately 40%, or more than 80,000

deaths each year. The editorialist provides a comparison: "Approximately

50,000 people die of breast cancer, and 150,000 deaths occur from lung

cancer each year. ALI is both common and life threatening, yet we lack

simple clinical tests to accurately diagnose and categorize patients

according to etiology, pathophysiology, and probable outcome."

"As the caretakers to the critically ill, our profession is continually

seeking evidenced-based solutions to improve patient care," says Joseph E.

Parrillo, M.D., editor-in-chief of Critical Care Medicine. "The research

supporting lower tidal volumes for ALI continues to grow."

Critical Care Medicine is the official journal of the Society of Critical

Care Medicine. It is the premier peer-reviewed, scientific publication in

critical care medicine. Each issue presents critical care practitioners with

clinical breakthroughs that lead to better patient care, the latest news on

promising research, and advances in equipment and techniques.

For more information, contact Elaine Salewske at (847) 827-7095 or

esalewske@sccm.org.

The Society of Critical Care Medicine is the leading professional

organization dedicated to ensuring excellence and consistency in the

practice of critical care medicine. With nearly 13,000 members worldwide,

the Society is the only professional organization devoted exclusively to the

advancement of multiprofessional intensive care through excellence in

patient care, professional education, public education, research and

advocacy. Members of the Society include intensivists, critical care nurses,

critical care pharmacists, clinical pharmacologists, respiratory care

practitioners and other professionals with an interest in critical care,

which may include physician assistants, social workers, dieticians, and

members of the clergy.

[Dustdevil]

I would get a lot more out of that if they provided a clearer definition of ALI, as well as some examples besides cancer.

[Ace844]

I would get a lot more out of that if they provided a clearer definition of ALI, as well as some examples besides cancer.

"Dust,"

This should provide some insight for you and those others who are wondering about your inquiry. I'm surprised you didn't try to dock "Squint, et.al.," a - 5 for posting this in a BLS forum.... :? :shock: 8)

[web:20fa9ae5f1]http://www.ards.org/learnaboutards/whatisards/brochure/[/web:20fa9ae5f1]

[web:20fa9ae5f1]http://www.emedicine.com/emerg/topic503.htm[/web:20fa9ae5f1]

[web:20fa9ae5f1]http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=35012[/web:20fa9ae5f1]

[web:20fa9ae5f1]http://www.ccmtutorials.com/rs/ali/09_alikp.htm[/web:20fa9ae5f1]

Hope this helps,

ACE844

[Ridryder 911]

Actually lowering your TV for potential ARDS and using Airway Pressure Release Ventilation has been out a while and does seem to be very promising. Many Paramedics in general over estimate their patients tidal volume bsed upon patients wieght rather than "ideal weight" and try to use the old ml/kg rule which is usually too much.

Thanks for the up-date guys.. we carry vents on each truck and routinely use them about every day, I wil post updates for training..

R/R 911

[AZCEP]

Maybe I'm oversimplifying this, but where would the "just enough to get good chest rise" fall into this? Also, does this mean that any process that creates an inflammatory response in the lungs would qualify? That would certainly be more than the ARDS and CA that has been discussed.

I've never been a fan of the NREMT standard of "800 mL per breath", especially when most can't squeeze the BVM enough to get it to happen.

[Dustdevil]

Ah, got it now.

ALI is new terminology for an old problem. Why can't the bastards just name something and leave it that way? :roll:

[Guest]

Actually lowering your TV for potential ARDS and using Airway Pressure Release Ventilation has been out a while and does seem to be very promising. Many Paramedics in general over estimate their patients tidal volume bsed upon patients wieght rather than "ideal weight" and try to use the old ml/kg rule which is usually too much.

Thanks for the up-date guys.. we carry vents on each truck and routinely use them about every day, I wil post updates for training..

R/R 911

Rid have you seen the VAR in your travels.

A Pressure Controller, in conjunction with ETCO2 (with a few alarms) its does a far job, disposable too.

http://www.vortran.com/

[AZCEP]

The VAR would probably be the better option for this situation. Since it is pressure sensing, it will stop the inspiratory cycle when the pressure is met. We use them, and really like the fact that they free up the solo medic to do other things for a short time.

[Guest]

"Dust,"

This should provide some insight for you and those others who are wondering about your inquiry. I'm surprised you didn't try to dock "Squint, et.al.," a - 5 for posting this in a BLS forum.... :? :shock: 8)

Ace;

Dust is aware that IPPB apparatus are within scope of practice here in Alberta, are you telling me that they cannot operate them where you reside? Very unfortunate; its the Alberta advantage I suspect.

Oh yes do you intend on having this forum locked as well or just out stalking me again?

[Ace844]

Ace;

Dust is aware that IPPB apparatus are within scope of practice here in Alberta, are you telling me that they cannot operate them where you reside? Very unfortunate; its the Alberta advantage I suspect.

Oh yes do you intend on having this forum locked as well or just out stalking me again?

"squint,"

Your correct in your supposition that this is not a BLS skill south of your border. Next it is never my intention to get any thread locked. That is a Moderator function, of which I don't perform, nor have influence over. But, you knew that, or perhaps that was a semi-sucessful attempt at being fecetious....?!?! :roll: :shock: :wink: 8)