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Background: Maintaining oxygenation during neonatal open repair of esophageal atresia/tracheoesophageal fistula is difficult. Inverse ratio ventilation can be used during one lung ventilation to improve the oxygenation and lung mechanics. Objective: The aim of this study was to describe the impact of two different ventilatory strategies (inverse ratio ventilation vs. conventional ratio ventilation) during one lung ventilation in neonatal open repair of esophageal atresia/tracheoesophageal fistula on the incidence of oxygen desaturation episodes. Methods: We enrolled 40 term neonates undergoing open right thoracotomy for esophageal atresia/tracheoesophageal fistula repair and randomly assigned into two groups based on inspiratory to expiratory ratio of mechanical ventilation parameters (2:1 in inverse ratio ventilation "IRV" and 1:2 in conventional ratio ventilation "CRV"). The incidence of desaturation episodes that required stopping the procedure and reinflation of the lung were recorded as the primary outcome while hemodynamic parameters, incidence of complications, and length of surgical procedure were recorded as the secondary outcomes. Results: There was a trend toward a reduction in the incidence of severe desaturations (requiring stopping of surgery) with the use of inverse ratio ventilation (15% in IRV vs. 35% in CRV, RR [95% CI] 0.429 [0.129–1.426]). Incidence of all desaturations (including those requiring only an increase in ventilatory support or inspired oxygen saturation) was also reduced (40% in IRV vs. 75% in CRV, RR [95% CI] 0.533 [0.295–0.965]). This in turn affected the length of surgical procedure being significantly shorter in inverse ratio ventilation group (mean difference −16.3, 95% CI −31.64 to −0.958). The intraoperative fraction of inspired oxygen required to maintain adequate oxygen saturation was significantly lower in the inverse ratio ventilation group than in the conventional ratio ventilation group (mean difference −0.22, 95% CI −0.33 to −0.098), with no significant difference in hemodynamic stability or complications apart from higher blood loss in inverse ratio group. Conclusion: There may be a role for inverse ratio ventilation with appropriate positive end‐expiratory pressure to reduce the incidence of hypoxemia during open repair of esophageal atresia/tracheoesophageal fistula in neonates, further studies are required to establish the safety and efficacy of this technique. [ABSTRACT FROM AUTHOR]

Abstract Background Obesity has become a global epidemic problem affecting every system and is associated with many consequences including coronary artery disease, hypertension, diabetes mellitus, dyslipidemia, obstructive sleep apnea, and socioeconomic and psychosocial impairment. Laparoscopic sleeve gastrectomy is one of the best and most commonly done operations for weight loss. Elevated peak airway pressure and hypoxemia are common problems that anesthesiologists face during laparoscopic surgeries with conventional volume-controlled ventilation. This study aimed at the use of the prolonged I:E ratio as an alternative strategy to improve gas exchange and the respiratory mechanics of obese patients undergoing laparoscopic sleeve gastrectomy. Results The study was a prospective randomized controlled trial and was performed between April 2019 and March 2020. After the approval of the departmental ethical committee and the informed written consent had been taken from the patients, fifty-two obese patients undergoing laparoscopic sleeve gastrectomy were enrolled in this study. After endotracheal intubation, the patients were randomly divided into the IRV group (n=26) and the VCV group (n=26). Respiratory parameters were adjusted as tidal volume (Vt) 8mL/kg ideal body weight, respiratory rate 12 breaths/min, positive-end expiratory pressure (PEEP) 0, fractional inspired oxygen (FiO2) 0.6, and I:E ratio 1:2 for the VCV group and 2:1 for the IRV group; hemodynamics and respiratory mechanics were monitored and recorded after intubation (0 min), before pneumoperitoneum (10 mins), and after pneumoperitoneum (20 mins), 30, 40, 50, and 60 mins. IRV significantly improves the respiratory mechanics during pneumoperitoneum in the form of decreasing the peak pressure (Ppeak) and plateau pressure (Pplat) and improving the dynamic compliance, but the mean pressure (Pmean) was increased; it also increased the partial pressure of oxygen (arterial PO2) significantly. No statistical significance was found regarding the demographic data or the hemodynamics. Conclusion IRV is superior to conventional VCV in morbidly obese patients undergoing laparoscopic sleeve gastrectomy as it improves respiratory mechanics and oxygenation.

Background and Aims: Induction of general anaesthesia is associated with development of atelectasis in the lungs, which may further lead to postoperative pulmonary complications. Inverse ratio ventilation (IRV) has shown to improve oxygenation and minimise further lung injury in patients with acute respiratory distress syndrome. We evaluated the safety and effectiveness of IRV on intraoperative respiratory mechanics and postoperative pulmonary function tests (PFTs). Methods: In a prospective, controlled study, 128 consecutive patients with normal preoperative PFTs who underwent elective laparoscopic cholecystectomy were randomised into IRV and conventional ventilation groups. Initially, all patients were ventilated with settings of tidal volume 8 mL/kg, respiratory rate 12/min, inspiratory/expiratory ratio (I: E) = 1:2, positive end expiratory pressure = 0. Once the pneumoperitoneum was created, the conventional group patients were continued to be ventilated with same settings. However, in the IRV group, I: E ratio was changed to 2:1. Peak pressure (Ppeak), Plateau pressure (Pplat) and lung compliance were measured. Haemodynamic parameters and arterial blood gas values were also measured. PFTs were repeated in postoperative period. Statistical tool included Chi-square test. Results: There was no significant difference in PFTs in patients who underwent IRV as compared to conventional ventilation [forced vital capacity (FVC) 2.52 ± 0.13 versus 2.63 ± 0.16, P = 0.28]. The Ppeak (cmH2O) and Pplat (cmH2O) were statistically lower in IRV patients [Ppeak 21.4 ± 3.4 versus 22.4 ± 4.2, P = 0.003] [Pplat 18.7 ± 2.4 versus 19.9.4 ± 3.2, P = 0.008]. There was no significant difference in lung compliance and oxygenation intraoperatively. Conclusion: Intraoperative IRV led to reduced airway pressures; however, it did not prevent deterioration of PFTs in postoperative period. [ABSTRACT FROM AUTHOR]

Background: Obesity has become a global epidemic problem affecting every system and is associated with many consequences including coronary artery disease, hypertension, diabetes mellitus, dyslipidemia, obstructive sleep apnea, and socioeconomic and psychosocial impairment. Laparoscopic sleeve gastrectomy is one of the best and most commonly done operations for weight loss. Elevated peak airway pressure and hypoxemia are common problems that anesthesiologists face during laparoscopic surgeries with conventional volume-controlled ventilation. This study aimed at the use of the prolonged I:E ratio as an alternative strategy to improve gas exchange and the respiratory mechanics of obese patients undergoing laparoscopic sleeve gastrectomy. Results: The study was a prospective randomized controlled trial and was performed between April 2019 and March 2020. After the approval of the departmental ethical committee and the informed written consent had been taken from the patients, fifty-two obese patients undergoing laparoscopic sleeve gastrectomy were enrolled in this study. After endotracheal intubation, the patients were randomly divided into the IRV group (n=26) and the VCV group (n=26). Respiratory parameters were adjusted as tidal volume (Vt) 8mL/kg ideal body weight, respiratory rate 12 breaths/min, positive-end expiratory pressure (PEEP) 0, fractional inspired oxygen (FiO2) 0.6, and I:E ratio 1:2 for the VCV group and 2:1 for the IRV group; hemodynamics and respiratory mechanics were monitored and recorded after intubation (0 min), before pneumoperitoneum (10 mins), and after pneumoperitoneum (20 mins), 30, 40, 50, and 60 mins. IRV significantly improves the respiratory mechanics during pneumoperitoneum in the form of decreasing the peak pressure (Ppeak) and plateau pressure (Pplat) and improving the dynamic compliance, but the mean pressure (Pmean) was increased; it also increased the partial pressure of oxygen (arterial PO2) significantly. No statistical significance was found regarding the demographic data or the hemodynamics. Conclusion: IRV is superior to conventional VCV in morbidly obese patients undergoing laparoscopic sleeve gastrectomy as it improves respiratory mechanics and oxygenation. [ABSTRACT FROM AUTHOR]

Specific aim: To examine the effects of pressure-controlled inverse ratio ventilation (PCIRV) and volume-control ventilation (VCV) on arterial oxygenation, pulmonary function, hemodynamics, levels of surfactant protein A (SP-A), and tumor necrosis factor-α (TNF-α) in obese patients undergoing gynecological laparoscopic surgery. Methods: Sixty patients, body mass index (BMI) ≥30 kg/m, scheduled for elective gynecological laparoscopic surgery were enrolled in the study. Patients were randomly allocated to receive either PCIRV with an inspiratory-expiratory (I:E) ratio of 1.5:1 (PCIRV group n = 30) or VCV with an I:E ratio of 1:2 (VCV group n = 30). Ventilation variables, viz. tidal volume ( V ), dynamic respiratory-system compliance ( C ), driving pressure (Δ P = V / C ), arterial blood oxygen partial pressure/fraction of inspiration oxygen (PaO/FiO) and arterial blood carbon dioxide partial pressure (PaCO), were measured. Hemodynamic variables, viz. mean arterial pressure (MAP), heart rate (HR), and serum levels of SP-A and TNF-α, were also measured. Results: When compared to patients in the VCV group, patients in the PCIRV group had higher V , dynamic C, and PaO/FiO, and lower Δ P and PaCO at 20 and 60 min after the start of pneumoperitoneum ( p < 0.05). Patients in the PCIRV group had lower SP-A and TNF-α levels at 24 and 48 h after surgery than those in the VCV group ( p < 0.05). Conclusion: In obese patients undergoing gynecological laparoscopic surgery, PCIRV can improve ventilation, promote gas exchange and oxygenation, and is associated with decreased levels of SP-A and TNF-α. These effects demonstrate improved lung protection provided by PCIRV in this patient population. [ABSTRACT FROM AUTHOR]

Background: Obese children undergoing laparoscopic surgery frequently experience high end-tidal carbon dioxide partial pressure (P ET CO 2 ) and respiratory acidosis. This study aimed to investigate the effects of pressure-controlled inverse ratio ventilation (IRV) with an inspiratory to expiratory ratio (I:E) of 1.5:1 on obese children undergoing laparoscopic surgery., Methods: Eighty children undergoing laparoscopic surgery were randomly assigned to either the IRV group (I:E=1.5:1) or the control group (I:E=1:1.5). The lungs were mechanically ventilated following tracheal intubation. The children underwent pressure-controlled ventilation with an I:E ratio of 1.5:1 or 1:1.5. Respiratory mechanics, hemodynamic values, and ventilation-related side effects were recorded., Results: Thirty minutes after establishing CO 2 pneumoperitoneum, the IRV group exhibited significantly higher tidal volume (Vt) and arterial partial pressure of oxygen (PaO 2 ) compared to the control group (97.6 ± 6.6 vs. 93.2 ± 8.0 ml, 283 ± 54 vs. 247 ± 40 mmHg, respectively) ( P < 0.01). Furthermore, PaCO 2 was significantly lower in the IRV group than in the control group (41.4 ± 5.8 vs. 45.5 ± 5.7 mmHg, P =0.002). The incidence of intra-operative hypercapnia was significantly decreased in the IRV group (25% vs. 42.5%, P =0.03)., Conclusion: Pressure-controlled IRV can reduce the incidence of hypercapnia, increasing Vt, and thereby improving CO 2 elimination in obese children undergoing laparoscopy. This ventilation technique significantly improves gas exchange in this patient population. (Registration number: ChiCTR2000035589)., Competing Interests: None., (AJTR Copyright © 2023.)

Background: It is well documented that pressure-controlled ventilation (PCV) improves oxygenation and ventilation compared to volume-controlled ventilation and reduces peak airway pressure in gynecological laparoscopy. PCV with moderately inversed inspiratory-expiratory (I: E) ratio can successfully recruit collapsed alveoli and has been proved to be beneficial in intensive care. We tested the hypothesis that altering the I: E ratio to 1.5:1 in PCV improves ventilation during gynecological laparoscopy using laryngeal mask airway (LMA). Objective: To study pressure-controlled inverse ratio ventilation (PCIRV) with I: E ratio 1.5:1 as against PCV with I: E ratio 1:2 in gynecological laparoscopy with LMA using noninvasive parameters. Materials and Methods: Intraoperative hemodynamics and side-stream spirometry recordings were noted in 20 consecutive patients undergoing major gynecological laparoscopy with LMA. Flexible LMA or LMA supreme were used depending on normal body mass index (BMI) or high BMI, respectively. Results: Reversing the I: E ratio to 1.5:1 increased the tidal volume, mean airway pressures, and dynamic lung compliance significantly, all indicating better oxygenation at comparable peak airway pressures as against PCV with I: E ratio 1:2. There was no change in the end-tidal carbon dioxide. There was no auto-positive end expiratory pressure (PEEP) or change in the hemodynamics. Conclusion: Reversal of I: E ratio with PCV can be beneficially used with LMA in laparoscopy.

Purpose: Low tidal volume ventilation improves the outcomes of acute respiratory distress syndrome (ARDS). However, no studies have investigated the use of a rescue therapy involving mechanical ventilation when low tidal volume ventilation cannot maintain homeostasis. Inverse ratio ventilation (IRV) is one candidate for such rescue therapy, but the roles and effects of IRV as a rescue therapy remain unknown. Methods: We undertook a retrospective review of the medical records of patients with ARDS who received IRV in our hospital from January 2007 to May 2014. Gas exchange, ventilation, and outcome data were collected and analyzed. Results: Pressure-controlled IRV was used for 13 patients during the study period. Volume-controlled IRV was not used. IRV was initiated on 4.4 ventilation days when gas exchange could not be maintained. IRV significantly improved the PaO/FiO from 76 ± 27 to 208 ± 91 mmHg without circulatory impairment. The mean duration of IRV was 10.5 days, and all survivors were weaned from mechanical ventilation and discharged. The 90-day mortality rate was 38.5 %. Univariate analysis showed that the duration of IRV was associated with the 90-day mortality rate. No patients were diagnosed with pneumothorax. Conclusions: Pressure-controlled IRV provided acceptable gas exchange without apparent complications and served as a successful bridge to conventional treatment when used as a rescue therapy for moderate to severe ARDS. [ABSTRACT FROM AUTHOR]

Aim: To observe the 28 and 90 days mortality associated with prone position and assist control-pressure control (with inverse ratio) ventilation (ACPC-IRV). Materials and Methods: All patients who were admitted to our medical Intensive Care Unit (ICU) who are positive for H1N1 viral infection with severe acute respiratory distress syndrome (ARDS) and requiring invasive mechanical ventilation in prone position were included in our prospective observational study. Six patients who are positive for H1N1 required invasive ventilation in prone position. These patients were planned to ventilate in prone for 16 h and in supine for 8 h daily until P/F ratio >150 with FiO2 of 0.6 or less and positive end-expiratory pressure <10 cm of H2O. Results: At admission, among these six patients the mean tidal volume generated was about 376.6 ml which was in the range of 6-8 ml/kg predicted body weight. The mean lung injury score was 3.79, mean PaO2/FiO2 ratio was 52.66 and mean oxygenation index was 29.83. The mean duration of ventilation was 9.4 days (225.6 h). The ICU length of stay was 11.16 days. There was no mortality at 28 and 90 days. Conclusion: Early prone combined with ACPC-IRV in H1N1 patients having severe ARDS can be used as a rescue therapy and it should be confirmed by large observational studies. [ABSTRACT FROM AUTHOR]

Objective: Cyclic recruitment and derecruitment of atelectasis can occur during mechanical ventilation, especially in injured lungs. Experimentally, cyclic recruitment and derecruitment can be quantified by respiration-dependent changes in Pao2 (ΔPao2), reflecting the varying intrapulmonary shunt fraction within the respiratory cycle. This study investigated the effect of inspiration to expiration ratio upon ΔPao2 and Horowitz index. Design: Prospective randomized study. Setting: Laboratory investigation. Subjects: Piglets, average weight 30 ± 2 kg. Interventions: At respiratory rate 6 breaths/min, end-inspiratory pressure (Pendinsp) 40 cm H2O, positive end-expiratory pressure 5 cm H2O, and Fio2 1.0, measurements were performed at randomly set inspiration to expiration ratios during baseline healthy and mild surfactant depletion injury. Lung damage was titrated by repetitive surfactant washout to induce maximal cyclic recruitment and derecruitment as measured by multifrequency phase fluorimetry. Regional ventilation distribution was evaluated by electrical impedance tomography. Step changes in airway pressure from 5 to 40 cm H2O and vice versa were performed after lavage to calculate Po2- based recruitment and derecruitment time constants (TAU). Measurements and Main Results: In baseline healthy, cyclic recruitment and derecruitment could not be provoked, whereas in model acute respiratory distress syndrome, the highest ΔPao2 were routinely detected at an inspiration to expiration ratio of 1:4 (range, 52–277 torr [6.9–36.9 kPa]). Shorter expiration time reduced cyclic recruitment and derecruitment significantly (158 ± 85 torr [21.1 ± 11.3 kPa] [inspiration to expiration ratio, 1:4]; 25 ± 12 torr [3.3 ± 1.6 kPa] [inspiration to expiration ratio, 4:1]; p < 0.0001), whereas the Pao2/Fio2 ratio increased (267 ± 50 [inspiration to expiration ratio, 1:4]; 424 ± 53 [inspiration to expiration ratio, 4:1]; p < 0.0001). Correspondingly, regional ventilation redistributed toward dependent lung regions (p < 0.0001). Recruitment was much faster (TAU: fast 1.6 s [78%]; slow 9.2 s) than derecruitment (TAU: fast 3.1 s [87%]; slow 17.7 s) (p = 0.0078). Conclusions: Inverse ratio ventilation minimizes cyclic recruitment and derecruitment of atelectasis in an experimental model of surfactant-depleted pigs. Time constants for recruitment and derecruitment, and regional ventilation distribution, reflect these findings and highlight the time dependency of cyclic recruitment and derecruitment. [ABSTRACT FROM AUTHOR]

Background: It is well documented that pressure-controlled ventilation (PCV) improves oxygenation and ventilation compared to volume-controlled ventilation and reduces peak airway pressure in gynecological laparoscopy. PCV with moderately inversed inspiratory-expiratory (I: E) ratio can successfully recruit collapsed alveoli and has been proved to be beneficial in intensive care. We tested the hypothesis that altering the I: E ratio to 1.5:1 in PCV improves ventilation during gynecological laparoscopy using laryngeal mask airway (LMA). Objective: To study pressure-controlled inverse ratio ventilation (PCIRV) with I: E ratio 1.5:1 as against PCV with I: E ratio 1:2 in gynecological laparoscopy with LMA using noninvasive parameters. Materials and Methods: Intraoperative hemodynamics and side-stream spirometry recordings were noted in 20 consecutive patients undergoing major gynecological laparoscopy with LMA. Flexible LMA or LMA supreme were used depending on normal body mass index (BMI) or high BMI, respectively. Results: Reversing the I: E ratio to 1.5:1 increased the tidal volume, mean airway pressures, and dynamic lung compliance significantly, all indicating better oxygenation at comparable peak airway pressures as against PCV with I: E ratio 1:2. There was no change in the end-tidal carbon dioxide. There was no auto-positive end expiratory pressure (PEEP) or change in the hemodynamics. Conclusion: Reversal of I: E ratio with PCV can be beneficially used with LMA in laparoscopy. [ABSTRACT FROM AUTHOR]

Introduction: Positive pressure ventilation influences hemodynamics and impairs renal function. The effects of inverse ratio ventilation (IRV) on hormonal response and renal function need to be investigated because this represents a highly invasive form of positive pressure ventilation. Materials and methods: Ten male patients were treated postoperatively for 60 min using five different ventilation modes. At the end of these periods, hemodynamics, urine production, fractional excretion of sodium (FESo), as well as the hormones, atrial natriuretic peptide (ANP), renin, angiotensin II, aldosterone, and antidiuretic hormone (ADH), were measured in plasma. Results: Central venous pressure (CVP), ADH, and renin with a positive end-expiratory pressure (PEEP) of 15 cm H2O and an inspiration/expiration ratio (I:E) of 1:2 revealed significant increases from baseline, whereas CVP, renin, and FESo showed an increase with an PEEP of 15 cm H2O and an I:E ratio of 2:1. Urine production significantly decreased with an PEEP of 15 cm H2O and an I:E ratio of 2:1. Conclusions: IRV with PEEP induced clear effects on hemodynamics and hormonal responses (renin) as well as a decrease in urine production in patients with healthy renal and pulmonary systems after an operation. However, all parameters apart from FESo and renin remained within the normal range. Whether pathological values are also observed after longer periods of positive pressure ventilation shall be the subject of other studies. [ABSTRACT FROM AUTHOR]

Inverse ratio ventilation (IRV) is a ventilatory technique that uses an inspiratory to expiratory ratio (I:E) greater than 1:1. We studied the effects of mechanical ventilation with an I:E of 1:3, 1:1, and 2:1 on arterial oxygenation in 10 patients with sepsis-associated acute respiratory distress syndrome (ARDS). At each I:E, patients received 0 and 4 ppm of inhaled nitric oxide (INO) in random order for 30 min. Respiratory and cardiovascular parameters were measured. Of the 10 patients studied, 7 responded to IRV and 3 did not. An increase in the I:E and the addition of INO significantly improved arterial oxygenation in the responders (p < 0.0001 and p < 0.006, respectively). The combination of an increase in the I:E and INO had an additive effect on arterial oxygenation. The combined use of IRV and INO is a more effective method of avoiding hypoxemia than either INO or IRV alone. [ABSTRACT FROM AUTHOR]

Background: Nitric oxide [NOexp] is present in exhaled air in many species. During experiments on pressure-controlled inverse ratio ventilation (PCIRV) in rabbits, increased [NOexp] was observed during PCIRV. The present study was undertaken to clarify which component of PCIRV increased [NOexp].Methods: Three groups of six New Zealand White rabbits were anaesthetised and mechanically ventilated. Exhaled nitric oxide, lung mechanics and gas exchange were measured using an experimental protocol designed to assess the effects of variations in 1) flow profile, 2) inspiratory time and 3) time-weighted tidal volume. Ventilator settings used were volume and pressure control ventilation at I:E ratios of 1:2 and 4:1.Results: Constant and decelerating flow gave comparable [NOexp] levels (20.0 +/- 6.4 vs. 21.9 +/- 7.7 ppb, n.s.) when time-weighted tidal volume was kept constant. Using conventional (I:E 1:2) or inverted (I:E 4:1) I:E ratios in combination with decelerating flow and constant time-weighted tidal volumes did not alter [NOexp] (26.0 +/- 3.6 vs. 24.0 +/- 5.8 ppb, n.s.). An increased time-weighted tidal volume produced by pressure control with an I:E ratio of 4:1 increased [NOexp] (29.6 +/- 7.4) in comparison to constant (19.3 +/- 4.1, P < 0.05) and decelerating flow ventilation (19.6 +/- 3.6, P < 0.05) with I:E ratios of 1:2.Conclusion: The exhaled NO concentration was affected by ventilator setting. Increased levels of [NOexp] were observed with increases in time-weighted tidal volume, whereas changes in flow pattern and inspiratory time did not seem to influence airway NO production or release. [ABSTRACT FROM AUTHOR]

Objective: To assess the magnitude of spontaneous variability of arterial oxygenation and oxygen tension-based indices over time in medical intensive care unit (ICU) patients and to study whether high positive end-expiratory pressure (PEEP) or inverse inspiratory-to-expiratory (I:E) ratio ventilation (IRV) results in a greater variability than low PEEP with conventional I:E ratio ventilation.Design: Prospective study.Setting: Medical ICU in a tertiary medical center.Participants: 23 patients requiring a pulmonary artery floating catheter for hemodynamic monitoring.Intervention: After being completely sedated, patients were randomized to receive pressure-control ventilation at setting A: high PEEP (15 cm H2O) with conventional I:E ratio (1:2) and setting B: inverse I:E ratio (2:1) with low PEEP (5 cm H2O) alternately, and then at setting C: low PEEP (5 cm H2O) with conventional I:E ratio (1:2). Each ventilation setting lasted 1 h.Measurements and Results: The arterial and mixed venous blood samples were measured simultaneously at baseline (time 0), and at 15, 30, 45, and 60 min thereafter. The coefficient of variation (CV) of arterial oxygen tension (PaO2) over time was 5.9 % for setting A, 7.2 % for setting B, and 6.9 % for setting C. ANOVA showed no significant differences in CVs of PaO2 between the three settings. Oxygen tension-based indices, alveolar-arterial oxygen difference (A-aDO2) and PaO2/ PAO2 (alveolar oxygen tension), displayed CVs equal to that of PaO2; the CV of A-aDO2/PaO2 was significantly greater than that of PaO2.Conclusions: In critically ill medical ICU patients, despite sedation, the spontaneous variability in PaO2 over time is substantial. A high PEEP or IRV does not contribute to the increased variation in PaO2. [ABSTRACT FROM AUTHOR]

Objectives: To study the ability of different ventilatory approaches to keep the lung open.Design: Different ventilatory patterns were applied in surfactant deficient lungs with PEEP set to achieve pre-lavage PaO2.Setting: Experimental laboratory of a University Department of Anaesthesiology and Intensive Care.Animals: 15 anaesthetised piglets.Interventions: One volume-controlled mode (L-IPPV201:1.5) and two pressure-controlled modes at 20 breaths per minute (bpm) and I:E ratios of 2:1 and 1.5:1 (L-PRVC202:1 and L-PRVC201.5:1), and two pressure-controlled modes at 60 bpm and I:E of 1:1 and 1:1.5 (L-PRVC601:1 and L-PRVC601:1.5) were investigated. The pressure-controlled modes were applied using "Pressure-Regulated Volume-Controlled Ventilation" (PRVC).Measurements and Results: Gas exchange, airway pressures, hemodynamics, FRC and intrathoracic fluid volumes were measured. Gas exchange was the same for all modes. FRC was 30% higher with all post-lavage settings. By reducing inspiratory time MPAW decreased from 25 cmH2O by 3 cmH2O with L-PRVC201.5:1 and L-PRVC601:1.5. End-inspiratory airway pressure was 29 cmH2O with L-PRVC201.5:1 and 40 cmH2O with L-IPPV201:1.5, while the other modes displayed intermediate values. End-inspiratory lung volume was 65 ml/kg with L-IPPV201:1.5, but it was reduced to 50 and 49 ml/kg with L-PRVC601:1 and L-PRVC601:1.5. Compliance was 16 and 18 ml/cmH2O with L-PRVC202:1 and L-PRVC201.5:1, while it was lower with L-IPPV201:1.5, L-PRVC601:1 and L-PRVC601:1.5. Oxygen delivery was maintained at pre-lavage level with L-PRVC201.5:1 (657 ml/min.m2), the other modes displayed reduced oxygen delivery compared with pre-lavage.Conclusion: Neither the rapid frequency modes nor the low frequency volume-controlled mode kept the surfactant deficient lungs open. Pressure-controlled inverse ratio ventilation (20 bpm) kept the lungs open at reduced end-inspiratory airway pressures and hence reduced risk of barotrauma. Reducing I:E ratio in this latter modality from 2:1 to 1.5:1 further improved oxygen delivery. [ABSTRACT FROM AUTHOR]

Objectives: To characterize different modes of pressure- or volume-controlled mechanical ventilation with respect to their short-term effects on oxygen delivery (DO2). Furthermore to investigate whether such differences are caused by differences in pulmonary gas exchange or by airway-pressure-mediated effects on the central hemodynamics.Design: After inducing severe respiratory distress in piglets by removing surfactant, 5 ventilatory modes were randomly and sequentially applied to each animal.Setting: Experimental laboratory of a university department of Anesthesiology and Intensive Care.Animals: 15 piglets after repeated bronchoalveolar lavage.Interventions: Volume-controlled intermittent positive-pressure ventilation (IPPV) with either 8 or 15 cmH2O PEEP; pressure-controlled inverse ratio ventilation (IRV); pressure-controlled high-frequency positive-pressure ventilation (HFPPV) and pressure-controlled high frequency ventilation with inspiratory pulses superimposed (combined high frequency ventilation, CHFV). The prefix (L) indicates that lavage has been performed.Measurements and Results: Measurements of gas exchange, airway pressures, hemodynamics, functional residual capacity (using the SF6 method), intrathoracic fluid volumes (using a double-indicator dilution technique) and metabolism were performed during ventilatory and hemodynamic steady state. The peak inspiratory pressures (PIP) were significantly higher in the volume-controlled low frequency modes (43 cmH2O for L-IPPV-8 and L-IPPV-15) than in the pressure-controlled modes (39 cmH2O for L-IRV, 35 cmH2O for L-HFPPV and 33 cmH2O for L-CHFV, with PIP in the high-frequency modes being significantly lower than in inverse ratio ventilation). The mean airway pressure (MPAW) after lavage was highest with L-IRV (26 cmH2O). In the ventilatory modes with a PEEP > 8 cmH2O PaO2 did not differ significantly and beyond this "opening threshold" MPAW did not further improve PaO2. Central hemodynamics were depressed by increasing airway pressures. This is especially true for L-IRV in which we found the highest MPAW and at the same time the lowest stroke index (74% of IPPV).Conclusions: In this model, as far as oxygenation is concerned, it does not matter in which specific way the airway pressures are produced. As far as oxygen transport is concerned, i.e. aiming at increasing DO2, we conclude that optimizing the circulatory status must take into account the circulatory influence of different modes of positive pressure ventilation. [ABSTRACT FROM AUTHOR]

In 19 anesthetized piglets 3 ventilatory modes were studied after inducing pulmonary insufficiency by bronchoalveolar lavage by the method of Lachmann. The lavage model was considered suitable for reproduction of severe respiratory distress. This model was reproducible and stable with respect to alveolar collapse, decrease in static chest-lung compliance and increase in extravascular lung water. The ventilatory modes studied were volume-controlled intermittent positive-pressure ventilation (IPPV), pressure-controlled inverse ratio ventilation (IRV), and pressure-controlled high-frequency positive-pressure ventilation (HFPPV). The 3 ventilatory modes were used in random sequence for at least 30 min to produce a ventilatory steady state. Ventilation with no PEEP, permitting alveolar collapse, was interposed between each experimental mode. The ability to open collapsed alveoli, i.e. alveolar recruitment, was different. The recruitment rate for IPPV was 74%, but for IRV and HFPPV it was 95%, respectively. Although IRV provided the best PaO2, this was at the expense of high airway pressures with circulatory interference and reduced oxygen transport. In contrast to this, HFPPV provided lower airway pressures, less circulatory interference and improved oxygen transport. In the clinical setting there might be negative effects on vital organs and functions unless the ventilatory modes are continuously and cautiously adapted to the individual requirements in different phases of severe respiratory distress. Therefore, one ventilatory strategy could be to "open the airways" with IRV, but then switch to HFPPV in an attempt to maintain the airways open with lesser risk of barotrauma and with improved oxygen transport. [ABSTRACT FROM AUTHOR]

Controlled mechanical ventilation is an accepted therapy for acute respiratory failure but by virtue of the increase in intrathoracic pressure has a large number of disadvantages. It is to overcome these disadvantages that alternative modes of ventilation have been introduced. These aim to reduce the effects of abnormally high airway pressure on the lung whilst recruiting solid alveoli and at the same time maintaining effective blood volume. Intermittent mandatory ventilation is a mode of ventilation first introduced to aid weaning which may reduce the need for sedation, permit better tolerance of high levels of PEEP and maintain urine osmolar output. High frequency ventilation utilising low airway pressures can maintain pulmonary gas exchange whilst reducing the effects of stretch on the lung. Its major role would seem to be in cases of bronchopleural fistula and necrotising pneumonia where a low mean airway pressure is essential. Low frequency positive pressure ventilation with extra corporeal CO2 removal, whilst a very labour intensive technique, has produced a favourable outcome in patients with terminal respiratory failure. Use of PEEP is associated with further deleterious haemodynamic effects which are largely overcome with use of continuous positive airway pressure during spontaneous respiration. PEEP is widely used. Its effect on pulmonary compliance, dead space and oxygen delivery are unpredictable making haemodynamic monitoring mandatory. Inversed ratio ventilation requires further evaluation whereas differential lung ventilation is logical, complicated but very valuable where the time constants for each lung are significantly different. [ABSTRACT FROM AUTHOR]

We have compared the cardiorespiratory effects of an inspiratory: expiratory (I:E) ratio of 4:1 with a ratio of 1:2 in 10 adult patients requiring intermittent positive pressure ventilation (IPPV) for acute respiratory insufficiency. Further comparisons were made with IPPV with positive end-expiratory pressure (PEEP) which was adjusted to achieve an equal external end-expiratory volume (EEEV) to that produced by the 4:1 ratio, as determined by respiratory inductive plethysmography, and with an I:E ratio that only changed the EEEV minimally (IRV-min). Percentage pulmonary shunt (Qs/Qt) was reduced equally with PEEP and with the 4:1 I:E ratio but both patterns reduced cardiac output and oxygen delivery. IRV-min also reduced Qs/Qt significantly but had no effect on cardiac output so that oxygen delivery was increased. The dead space to tidal volume ratio (VD/VT) during IPPV-4:1 and IRV-min was reduced significantly when compared with that during IPPV-1:2. The clinical implications of the findings suggest that for some ITU patients, a modest increase in I:E ratio to between 1.1:1 and 1.7:1 may produce better gas exchange without significantly effecting the cardiac output. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effect of inverse ratio ventilation (IRV) combined with positive end-expiratory pressure (PEEP) in infants undergoing thoracoscopic surgery with single lung ventilation (OLV) for lung cystadenomas., Methods: A total of 66 infants undergoing thoracoscopic surgery with OLV for lung cystadenomas in our hospital from February, 2018 to February, 2019 were randomized into conventional ventilation groups (group N, n =33) and inverse ventilation group (group R, n =33). Hemodynamics and respiratory parameters of the infants were recorded and arterial blood gas analysis was performed at 15 min after two lung ventilation (TLV) (T 1 ), OLV30 min (T 2 ), OLV60 min (T 3 ), and 15 min after recovery of TLV (T 4 ). Bronchoalveolar lavage fluid was collected before and after surgery to detect the expression level of advanced glycation end product receptor (RAGE)., Results: Sixty-three infants were finally included in this study. At T 2 and T 3 , Cdyn, PaO 2 and OI in group R were significantly higher ( P &lt; 0.05) and Ppeak, PaCO 2 and PA-aO 2 were significantly lower than those in group N ( P &lt; 0.05). There was no significant difference in HR or MAP between the two groups at T 2 and T 3 ( P &gt; 0.05). The level of RAGE significantly increased after the surgery in both groups ( P &lt; 0.05), and was significantly lower in R group than in N group ( P &lt; 0.05)., Conclusions: In infants undergoing thoracoscopic surgery with OLV for pulmonary cystadenoma, appropriate IRV combined with PEEP does not affect hemodynamic stability and can increases pulmonary compliance, reduce the peak pressure, and improve oxygenation to provide pulmonary protection.