_

ALI / ARDS

(Introduction)

( Methodology )

10

11

11

12

13

13

ALI / ARDS

14

(protective lung strategy)

20

20

22

ALI / ARDS

45

ALI / ARDS

45

ALI / ARDS

46

ALI / ARDS

49

25

( positive end-expiratory pressure, PEEP )

ALI / ARDS

25

27

Pressure-volume curve

29

(recruitment maneuvers, RM)

30

41

(Airway Pressure Release Ventilation, APRV)

APRV

41

APRV

42

52

 (Introduction)

acute respiratory distress syndrome, ALI /

ARDS1967

ARDS
( acute lung injury, ALI)ALI / ARDS

( ventilator-induced lung injuryVILI )

,

ALI / ARDS

lung protective ventilation strategy

ALI / ARDS

ALI / ARDS

()


ALI / ARDS

 ( Methodology )

/ALI / ARDS
ARDS network PubMed:
MedlineCochrane Library 1998 2008

16

1.

,,

2.

(low tidal volume

)6-8 ml/kgplateau

pressure, Pplat30-35cmH2O(mortality rate)

( permissive hypercapnea)(positive end-expiratory pressure,
PEEP)(airway pressure release ventilation, APRV)

(Scottish Intercollegiate Guidelines Network, SIGN)1,2

(meta analysis)(systematic

1++

reviews)(randomized control trials, RCTs)

(bias)

1+

1-

1. (case-control study)(cohort

2++

study)
2.


2+

2-

1.
1++(target
population)
2.(systematic reviews)(RCTs)
1+

1.2++

2. 1++1+

1.2+

2.2++

1.3 4

10

2.2+
C D
ABCD

11

AECC

American-European

consensus conference

ALI

acute lung injury

APRV

airway pressure release

ventilation

ARDS

acute respiratory distress

syndrome

LIP

low inflection point

PBW

predicted body weight

PCV

pressure control mode

PEEP

positive end-expiratory

pressure

PHY

permissive hypercapnia

Pplat

airway plateau pressure

PV curve

pressure-volume curve

RM

recruitment maneuvers

RR

respiratory rate

UIP

upper inflection point

VILI

ventilator-induced lung

injury

VT

tidal volume

12

1967 Ashbaugh 1 12

X
(adult Respiratory Distress SyndromeARDS )

ALI / ARDS

ALI / ARDS 1988

Murray 2 :
X oxygenation index, PaO2/FiO2
positive end-expiratory pressure, PEEP
0.12.4 ALI 2.5 ARDS
2
1994 - (American-European consensus
conferenceAECC) 3 ALI / ARDS
(Acute Respiratory Distress Syndrome) ALI / ARDS

X
18mmHg
ALI PaO2/FiO2 300 mmHg ARDSPaO2/FiO2 200
mmHg 3,4

13

ALI / ARDS
ALI/ALI / ARDS 5,6
ALI / ARDS Gattinoni

5,7-11,12 ALI / ARDS

ALI / ARDS
: ALI / ARDS 48%
22-38%6
4
ALI / ARDS

1.:

2.(
)

1.:
2.

ARDS 13
(exudative phase) 1
3

14


fibroproliferative phase
3 7

cyst
PaO2FiO2300 Acute lung
injury, ALI
PaO2FiO2200 ARDS

ALI / ARDS

( Ventilator-induced lung injuryVILI )

ALI / ARDS
pH

15

 VT10-15 ml/kg 20

VILI

VILI volutrauma
atelectrauma
biotrauma
barotrauma
oxygen toxicity
ALI / ARDS
12 3
ventral part

( recruitment-decruitment

dorsal part

13

14-15

VILI

16


(protective lung strategy)

tidal volume, VTairway plateau pressure,

Pplat
2007 Cocharane 1
ALI / ARDS 28
10 6
2-7

1181

1030 28
2.3.4
ALI / ARDS VT 12 ml/kg
6 ALI/ARDS Network3
861 ALI / ARDS

VT 6 ml/kg , Pplat 30 cmH2O

VILI Pplat
transpulmonary pressurePplat
Pplat
mato2 ARDS network3 Low VT 6 ml/kg
Pplat 30 cmH2O 2004 Cochrane
5 2-6 Pplat30 cmH2O

17

Low VT Pplat30 cmH2O Low

VT Pplat 30 cmH2O
ALI / ARDS VT 6 ml/ kg 4-8 ml
/kg, Pplat 30 cmH2O 19-24
Pplat 30 cmH2O VT kg 1 ml VT 4
ml/kg
25 cmH2OPplat30 cmH2O
VT 7-8 ml/kg Pplat 30 cmH2O
Pplat25 cmH2O VT kg 1 ml Pplat
25 cmH2O VT 6 -8 ml/kg

(dry body weightDBW)4

measured body weight, MBW2idea body
weight, IBW6predicted body weight, PBW3,5,7
IBW PBD
Steward6 IBW 7.0 ml/kg ALI / ARDS
Netwok3 PBD 8.0 ml/kg Brochard4
DBW 7.1 ml /kg PBD 7.8 ml /kgPBD
70kg 100

ALI / ARDS Netwok3 PBD

:PBW=50+0.91( cm -152.4): PBW=45+0.91( cm
-152.4)
18

PBW

kg = ( - 80 )X 0.7 10%
kg

= ( - 70 )X 0.6 10%

:170 cm 63 kg
56.7-69.3 kgPBW 66kg

Pplat30 cmH2O

permissive hypercapnia9,10,11

:
pH
10 mmHg/hr12 pH 7.257.45 2,3,13,14

(SaO290%)
15
pH7.235

auto-PEEP 35 /
PaCO225mmHg, sodium bicarbonate 16,17

19

:
12

12,17,18

20

 ALI / ARDS

ALI / ARDS
1B
Pplat30 cmH2O
VT
1B
VT 6 ml/ kg 4-8 ml/kg
pH
7.25-7.4535 / PaCO2 pH
pH7.2
1C
: PaO2 55-80 mmHgSpO2 88-95%PEEP
1B

ARDS Network Low PEEP /FiO2 table

ALI / ARDS PEEP

2C

21


ALI / ARDS
ALI / ARDS
-
VT 6 ml/ kg 4-8 ml/kg Pplat30 cmH2O
1.
1VC mode PC mode
VT Pplat
2. VT Pplat
1VT
A.

= ( - 80 )X 0.7
= ( - 70 )X 0.6
B. PBW
:PBW=50+0.91( cm -152.4)
: PBW=45+0.91( cm -152.4)
2 VT 6 ml/kgPplat30 cmH2O

A. Pplat30 cmH2OVT kg 1 ml VT 4
ml/kg
B. 25 cmH2O Pplat 30 cmH2OVT 6 ml/kg

VT 7-8 ml/kg Pplat30

cmH2O

22

C. Pplat25 cmH2OVT kg 1 ml Pplat 25

cmH2O
3. RR
1 RR 12-25 / RR 35 /
pH PaCO2 .
A. Pplat30 cmH2O
pH7.25

B. pH7.25 hypercapnia
35

auto-peep metabolic acidosis

underlying
sodium bicarbonate
C. pH7.15 sodium bicarbonate
VT 1 ml/kg pH7.15Pplat 30
cmH2O
2
.
A. VTRRPplatSpO2 PplatpH
15

: PaO2 55-80 mmHgSpO2 88-95%

1.PEEP:
PEEP5 cmH2O
2. ALI / ARDS Network Low VT FiO2/PEEP Table

23

3. PEEP10 cmH2O PEEP 2

cmH2O PaO2 55-80 mmHgSpO2 88 PEEP
PEEP

4.PaO2 SpO2
30 FiO2 PEEP
15

5. ALI / ARDS
40-50 cmH2O1
CPAP 40cmH2O40 2
PEEP PEEP
20 cmH2O 5-10 PEEP 2-5 cmH2O

6. FiO2 100%PaO2 60mmHg SpO2 88 1

(prone
position )inhalation nitric oxide

high frequency oscillation

7. ALI / ARDS APRV BIPAP

24

ALI / ARDS
:

ALI / ARDS
:
PEEP PaO2 / FiO2
24

48

1
1. PaO2 60mmHg FiO240-50%
2. PEEP 5-8 cmH2O
3. VT 5ml/kg 6 /RR30 /
4.minute ventilation10 L/m
5.MIP-20cmH2O

25


( positive end-expiratory pressure, PEEP )
ALI / ARDS

ALI / ARDS Type I

VILI 1-3
()
PEEP
alveolar recruitment
1 ALI / ARDS
dependent lung
Gattinoni
PEEP 11-14cmH2O
4

26


FiO2/PEEP Tables
PEEP 40-41
Suter 5 PEEP
VT 5-7 ml/kgPEEP

PEEP

PaO2/FiO2 ratio X
42
ALI / ARDS Netwok6
800 PV curve
Low PEEP/FiO2 table
PEEP / FiO2Tables

ALVEOLI High PEEP / FiO2 table 7 Amato 8

PEEP
ALI / ARDS Netwok6 Low PEEP / FiO2 Tables FiO2 40%
-80 %PEEP 8-14 cmH2O 5-15
cmH2O 800 6 78%
PEEP10 cmH2O 3% PEEP15
cmH2O9
-static pressure-volume curve,
PV curve(low inflection point, LIP)
PEEP 16 197

27

 LIP 10.84.7 cmH2O 50% LIP10

cmH2O84% LIP15 cmH2O 2 ALI / ARDS Netwok
Low PEEP/FiO2 table ALI
/ ARDS Netwok
Pplat30mmHgPaO2 55-80mmHg
PEEP FiO2 FiO2 50%PEEP 10 cmH2OFiO2
90%PEEP 14 cmH2O
ALI / ARDS ALI / ARDS Netwok Low PEEP /
FiO2 table

High PEEP/Low VT
Low VT Amato
Open-lung Approach
Low VT High PEEP
LIP+2 cmH2O

6,7,8 Amato Villar Open lung

Low VT High PEEP
ALVEOLI 7 Low PEEP High PEEP ALI
/ ARDS 8-9 cmH2O
14-15 cmH2O High PEEP

579 Low PEEP High PEEP

Mercat39
PEEP 5-9 cmH2O ALVEOLI 7 High PEEP/ FiO2Table 767
28

 ALI/ARDS :High PEEP

28 60
ALI / ARDS
High PEEP

Pressure-volume curve
Suter 10 -
pressure-volume curve, PV curve ALI / ARDS
PV curve S

low inflection point, LIP

LIP

upper inflection point, UIP

LIP UIP
UIP

29

 1,10ALI / ARDS
(shear force)
Ranieri11 static PV curve
Amato staticPV curve PEEP
LIP+2 cmH2OPEEP LIP
12,13 CT LIP
14,15 PEEP LIP
PEEP LIP UIP
PV curve
closing
pressure
PEEP 44
static PV curve

supersyringe15
(multiple occlusion technique)216
(low flow technique)17,18
LIP UIP
16 PV curve

(recruitment maneuvers, RM)

19

30

 PEEP ALI / ARDS

residual volume, RV total lung capacity,

TLC
PEEP
20 ALI / ARDS 14,21-23
24 25

45

sustained High pressure

continue positive airway pressure, CPAP35-50

cmH2O 20-40 8,26-28 PEEP
30-40 cmH2O PEEP

pressure support, PS

pressure control ventilation, PCV

1. PCV with PEEP method

29,30,31

peak inspiratory pressure,

31

PIP PEEP:PCV PEEP UIP3

cmH2OPIP 50 cmH2O 2 PEEP
20 cmH2OPIP35 cmH2O 29
2. Step-wise
incremental PEEP 21,22,32driving
pressure PEEP 15-20
cmH2O22,32 PEEP PIP
20 cmH2O PIP PEEP
20 cmH2O: PEEP 20 cmH2O PIP 40
cmH2O PEEP 25 cmH2O PIP 45
cmH2O PC`mode CPAP
PC mode
21,22,23,34

Borges (maximum lung recruitment)

15 cmH2OPEEP 25
cmH2OPIP 40cmH2O PEEP+5 cmH2O 2
PEEP 25
cmH2O 2 :PEEP / PIP
25/4030/4525/4035/50
PIP 60cmH2O22

(Sighs)
6-8ml/kg
32

 3 45 cmH2 35 PEEP

VT/PEEP8 / 106 / 154 / 20

2/ 25
CPAP 30 cmH2O 30 36

PEEP
Gattinoni 21 CT RM
PEEP PEEP
RM PEEP
PEEP LIP+2cmH2O8 LIP+4cmH2O18
15 16 cmH2O7,8 PEEP
decremental PEEP
:20 cmH2O23,29,38
25cmH2O22 5-10 PEEP 2-5 cmH2O
SpO290 PaO260mmHg

Oczenski30 PEEPbest PEEP

20%Borges
22

PaO2+PaCO2400 mmHg PEEP

CT PaO2+PaCO2400 mmHgFiO2 100%

5%
fully recruit
PEEP
6 PEEP PEEP
optimal PEEP

33

Grasso 26 RM 2 PaO2 / FiO2

1 7 175% vs
20%
RM ALI / ARDS
RM
ALI / ARDS
ALI / ARDS 14,21,22,23
RM LiM6
RM+PEEP 1
Grasso 26RM
20
PaO2/ FiO2 50
Lapinsky27 RM 4
RM decremental PEEP
4-6 22,23,26 Borges Pplat
40 cmH2OPEEP 25 cmH2O 54%
PaO2+PaCO2400 mmHg 60
cmH2ORM Optimal
PEEP PEEP 6 22
Meade 37 RM 983
: VT 6ml/kgPplat30 cmH2OPEEP Low
FiO2 / PEEP tableRM VT 6ml/kgPplat40 cmH2ORM40
PEEP high FiO2/ PEEP table
cmH2O40 FiO2 1.0
RM 4 FiO2 40%RM PaO2 / FiO2
:
RM

34

ICU 28

RM
18 27,38 37 Richard
18 PEEP
PEEP
Grasso38
PEEPLIP+3-4 cmH2O RM

ALI / ARDS Network28 High PEEP / FiO2 RM

RM SpO2 1 RM
RM
RM SpO2FiO2 / PEEP PEEP
PEEP RM
RM 28,30,37,38
21,22,30,35
983
43
RM

ALI / ARDS

Talmor D45

35

 PEEP PaO2/FiO2

36

 (Airway
Pressure Release Ventilation, APRV)
APRV
(acute respiratory distress syndrome, ALI / ARDS)

(ventilator-induced lung injury,

VILI) (airway pressure release ventilation, APRV)
(continuous positive airway
pressure, CPAP) CPAPP high
CPAPPlow1 CPAP CPAP
2

3,14

APRV
4

5,6

7APRV
8 APRV

9,10

37

 APRV
APRV (P/V curve) Phigh Plow
upper inflection point Phigh
(overdistension) low inflection point Plow
(recruitment /derecruitment) 11
APRV T-PEFR(peak expiratory flow
rate termination) > 50% and < 75%12
Phigh Phigh Thigh 13
T-PEFR 50 - 75%
T-PEFR 75% Tlow
T-PEFR 50% T-PEFR 50% Tlow T-PEFR 50%
Phigh APRV
ALI / ARDS APRV

APRV

(ventilation-perfusion matching)APRV

Phigh Plow
Thigh Tlow IE Phigh
Plow Thigh Tlow IE

38

APRV

39

1. Scottish Intercollegiate Guidelines Network. SIGN 50: a guideline

developers handbook. Edinburgh: SIGN, 2001.
2. Harbour R, Miller J. for the Scottish Intercollegiate Guidelines Network
Grading Review Group. A new system for grading recommendations in
evidence based guidelines. BMJ 2001; 323:334-6.

40


Series (ref. NO.)

Article title

Artigas A et al.

The American-European Consensus

19984

Conference on ALI / ARDS, Part 2.

Evidence
level
2+

Ventilatory, pharmacologic, support therapy,

study design strategies and issues related to
recovery and remodeling.
Gattinoni L et al.

Acute respiratory distress syndrome caused

19987

by pulmonary and extrapulmonary disease:

2++

different syndromes
Kallet RH. et al.

Do the NIH ALI / ARDS Clinical trials

200710

network

2+

PEEP/FIO2 tables provide the best

evidence-based guide to balancing PEEP and
FIO2 settings in Adults?
Atabai K et al.

The pulmonary physician in critical care .5:

200211

Acute lung injury and the acute respiratory

2-

distress syndrome: definitions and

epidemiology
Ware LB. et al.

The acute respiratory distress syndrome.

2+

Gattinoni L et al.

Effect of prone positioning on the survival of

1++

200112

patients with acute respiratory failure.

Zhang H et al.

Conventional mechanical ventilation is

200214

associated with bronchoalveolar

20005

41

lavage-induced activation of
polymorphonuclear leukocytes: a possible
mechanism to explain the systemic
consequences of ventilator-induced lung
injury in patients with ALI / ARDS.
Leaver SK. et al.

Acute respiratory distress syndrome.

2-

20076
Ranieri VM. et al. Effect of mechanical ventilation on
199915

1++

inflammatory mediators in patients with acute

respiratory distress syndrome: a randomized
controlled trial.

42


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10. Kallet RH, Branson RD. Do the NIH ALI / ARDS Clinical trials network
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44


Series (ref. NO.)
Leaver SK et al.

Article title
Acute respiratory distress syndrome.

20077
Atabai K et al.

The pulmonary physician in critical care c 5:

20029

Acute lung injury and the acute respiratory

distress syndrome: definitions and

Evidence
level
2-

2-

epidemiology.
Bream-Rouwenh

Recent developments in the management of

orst HR et al.

acute respiratory distress syndrome in adults.

1-

200810
Amato MB et al.

Effect of a protective-ventilation strategy on

19982

mortality in the acute respiratory distress

1+

syndrome.
ALI / ARDS

The acute respiratory distress syndrome

Network

network. Ventilation with lower tidal volumes

20003

as compared with traditional tidal volumes for

1++

acute lung injury and the acute respiratory

distress syndrome.
Brochard L et al.

Tidal volume reduction for prevention of

19984

ventilator induced lung injury in acute

respiratory distress syndrome. The

1+

multicenter trial group on Tidal Volume

reduction in ALI / ARDS.
Brower RG et al.

Prospective, randomized controlled clinical

1+

45

19995

trial comparing traditional versus reduced

tidal volume ventilation in acute respiratory
distress syndrome patients.

Stewart TE et al.

Evaluation of a ventilation strategy to prevent

19986

barotraumas in patient at high risk for acute

1+

respiratory distress syndrome. Pressure and

volume limited ventilation strategy group.
Villar J et al.

A high positive end-expiration pressure,

20067

lowtidal volume ventilatory strategy improves

outcome in persistent acute respiratory

1+

distress syndrome: a randomized, controlled

trial.
Petrucci N et al.

Lung protective ventilation strategy for the

20071

acute respiratory distress syndrome.

Bigatello LM et

Permissive hypercapnia.

1++

1-

al. 200110
Fehil F et al.

Permissive hypercapnia impairs pulmonary

200015

gas exchange in the acute respiratory distress

2+

syndrome.
Eddy Fan et al.

Ventilatory Management of Acute Lung

200519

Injury and Acute Respiratory Distress

1-

Syndrome
Petrucci N et al

Ventilation with smaller tidal volumes: a

200420

quantitative systematic review of randomized

1++

controlled trials.
Eichacker PQ. et

Meta-Analysis of Acute Lung Injury and

al 200221

Acute Respiratory Distress Syndrome Trials

1++

46

Testing Low Tidal Volumes.

Malhotra Atul.

Low tidal volume ventilation in the acute

200722

respiratory distress syndrome

Moloney E D et

Protective ventilation of patients with acute

al. 200423

respiratory distress syndrome

Kallet RH.

Evidence -Based management of acute lung

200424

Injury and Acute Respiratory Distress

2+

2-

2+

Syndrome.

47


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49

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JAMA. 2005;294:2889-2896.
20. Petrucci N, Iacovelli W. Ventilation with Smaller Tidal Volumes: A
Quantitative Systematic Review of Randomized Controlled Trials. Anesth.
Analg. 2004;99:193-200.
21. Eichacker PQ, Gerstenberger EP, Banks S M, et al Meta-Analysis of Acute
Lung Injury and Acute Respiratory Distress Syndrome Trials Testing Low
Tidal Volumes Am J Respir Crit Care Med 2002; 166: 1510-1514.
22. Malhotra Atul. Low tidal volume ventilation in the acute respiratory
distress syndrome N Engl J Med. 2007;357:1113-20.
23. Moloney E D, Griffths MJD. Protective ventilation of patients with acute
respiratory distress syndrome Br J Anaesth 2004; 92: 26170.
24. Kallet RH. Evidence-Based management of acute lung injury and acute
respiratory distress syndrome. Respir care 2004;49:793-809.

50

 ALI / ARDS

1. Macintyre NR, Evidence-Based Ventilator Weaning and Discontinuation

Ventilatory support :A Collective Task Force Facilitated by the American
College of Chest Physicians; the American Association for Respiratory
Care; and the American College of Critical Care Medicine .chest
2001;120:375-396.

51

( positive end-expiratory pressure, PEEP )

Series (ref. NO.)

Article title

Levy MM.

Optimal peep in ALI / ARDS changing

20021

concepts and current controversies.

Kallet RH et al.

Do the NIH ALI / ARDS Clinical Trials

20072

Network PEEP/FIO2 Tables Provide the Best

Evidence
level
2+

2+

Evidence-Based Guide to Balancing PEEP

and FIO2 Settings in Adults?
Acosta P et al.

The use of positive end-expiratory pressure in

20073

mechanical ventilation.

MachIntyre N.

Is there a best way to set positive

200840

expiratoryend Pressure for mechanical

2+

2+

ventilatory support in acute lung injury?

Brower RG et al.

National Heart, Lung, and Blood InstituteALI

20047

/ ARDS Clinical Trials Network. Higher

2+

versus lower positive endexpiratory pressures

in patients with the acute respiratory distress
syndrome.
Thompson BT et

Clinicians approaches to mechanical

al.

ventilation in acute lung injuryand ALI /

20019

ARDS.

Mercat A et al.

Positive End-Expiratory Pressure Setting in

200839

Adults With Acute Lung Injury and Acute

2+

1++

Respiratory Distress Syndrome: A

52

Randomized Controlled Trial.

Grasso S et al.

Effects of High versus Low Positive

200526

End-Expiratory Pressures in Acute

2+

Respiratory Distress Syndrome.

Mergoni M et al.

Lower inflection point and recruitment with

200112

PEEP in ventilated patients with acute

2++

respiratory failure.
Jonson B et al.

Pressurevolume curves and compliance in

199913

acute lung injury: evidence of recruitment

2+

above the lower inflection point.

Mehta S et al.

Temporal change, reproducibility, and

200316

interobserver variability in pressure-volume

2+

curves in adults with acute lung injury and

acute respiratory distress syndrome.
Crotti S et al.

Recruitment and derecruitment during acute

2-

200114

respiratory failure: a clinical study.

Pelosi P et al.

Sigh in acute respiratory distress syndrome.

2+

Mergoni M et al.

Lower inflection point and recruitment with

2-

200126

PEEPin ventilated patients with acute

199915

respiratory failure.
Richard 2 et

Influence of tidal volume on alveolar

al.00118

recruitment

Levy MM

Optimal peep in ALI / ARDS changing

200241

concepts and current controversies.

Mols G et al.

Alveolar recruitment in acute lung injury.

1-

2+

2+

53

200645
Villar J et al.

A high positive end-expiration pressure,

200643

lowtidal volume ventilatory strategy improves

1+

outcome in persistent acute respiratory

distress syndrome: a randomized, controlled
trial.
Pelosi P et al.

Sigh in acute respiratory distress syndrome.

2+

Caironi P et al.

Acute lung injury/acute respiratory distress

2-

200842

syndrome pathophysiology: what we have

199935

learned from computed tomography scanning.

Borges JB et al.

Reversibility of Lung Collapse and

200622

Hypoxemia in Early Acute Respiratory

2++

Distress Syndrome.
Lapinsky SE et

Safety and efficacy of a sustained inflation

al.

for alveolar recruitment in adults with

199927

respiratory failure.

Grasso S et al.

Effects of recruiting maneuvers in patients

200238

with acute respiratory distress syndrome

2-

1-

ventilated with protective ventilatory strategy.

Villagra A et al.

Recruitment maneuvers during lung

200229

protective ventilation in acute respiratory

2+

distress syndrome.
ALI / ARDS

Effects of recruitment maneuvers in patients

Network 2003

with acute lung injury and acute respiratory

28

distress syndrome ventilated with high

2++

positive end-expiratory pressure*.

54

Meade MO et al.

Ventilation strategy using low tidal volumes,

200837

recruitment maneuvers, and high positive

1++

end-expiratory pressure for acute lung injury

and acute respiratory distress syndrome: a
randomized controlled trial.
Oczenski W et al

Recruitment maneuvers after a positive

200430

end-expiratory pressure trial do not induce

1-

sustained effects in early adult respiratory

distress syndrome.
Lim CM et al

Effect of alveolar recruitment maneuver in

200336

early acute respiratory distress syndrome

1+

according to antiderecruitment strategy,

etiological category of diffuse lung injury,
and body position of the patient
Gattinoni L et al

Lung recruitment in patients with the acute

200621

respiratory distress syndrome.

Bugedo G, et al.

Lung computed tomography during a lung

200332

recruitment maneuver in patient with acute

2+

2+

lung injury.
Talmor D, et al.

Mechanical Ventilation Guided by

200845

Esophageal Pressure in Acute Lung Injury

1+

55

( positive end-expiratory pressure, PEEP )

1. Levy MM. Optimal peep in ALI / ARDS changing concepts and current
controversies. Critical Care Clinics.2002;18:15-33.
2. Kallet RH, Branson RD.Do the NIH ALI / ARDS Clinical Trials Network
PEEP/FIO2 Tables Provide the Best Evidence-Based Guide to Balancing
PEEP and FIO2 Settings in Adults? Respir Care 2007;52:461 475.
3. Acosta P, Santisbon E, Varon J .The use of positive end-expiratory
pressure in mechanical ventilation. Crit Care Clin 2007;23:251-261.
4. Gattinoni L, DAndrea L, Pelosi P, et al.Regional effects and mechanism of
positive end-expiratory pressure in early adult respiratory distress
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end-expiration pressure, lowtidal volume ventilatory strategy improves
outcome in persistent acute respiratory distress syndrome: a randomized,
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protective-ventilation strategy on mortality in the acute respiratory distress
syndrome. N Engl J Med 1998;338:347-354.
9. Thompson BT, Hayden D, Matthay MA, et al.Clinicians approaches to
mechanical ventilation in acute lung injuryand ALI / ARDS. Chest

56

2001;120:16221627.
10. Suter PM, Fairley HB, Isenberg MD. Optimum end-expiratory airway
pressure in patients with acute pulmonary failure. N Engl J Med
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pressure on alveolar recruitment and gas exchange in patients with the adult
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12. Mergoni M, Volpi A, Bricchi C, et al. Lower inflection point and
recruitment with PEEP in ventilated patients with acute respiratory failure.
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13. Jonson B, Richard JC, Strauss C, et al. Pressurevolume curves and
compliance in acute lung injury: evidence of recruitment above the lower
inflection point. Am J Respir Crit Care Med 1999;159:1172-1178.
14. Crotti S, Mascheroni D, Caironi P, et al. Recruitment and derecruitment
during acute respiratory failure: a clinical study. Am J Respir Crit Care
Med 2001; 164: 131140.
15. Pelosi P, Cadringher P, Bottino N et al. Sigh in acute respiratory distress
syndrome. Am J Respir Crit Care Med 1999; 159: 872880.
16. Mehta S, Stewart TE et al. Temporal change, reproducibility, and
interobserver variability in pressure-volume curves in adults with acute
lung injury and acute respiratory distress syndrome. Crit Care Med
2003;31:2118-2125.
17. Qin Lu, Silvia R, Vieira R et al. A Simple Automated Method for
Measuring Pressure-Volume Curves during Mechanical Ventilation. Am. J.
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18. Richard JC, Maggiore SM, Jonson B, et al..Influence of tidal volume on
alveolar recruitment. Am. J. Respir. Crit. Care Med. 2001; 163: 1609-1613.

57

19. Drefuss D, Saumon G.Ventilator-induced lung injury:lessons from

experimental studies. Am J Respir Crit Care Med 1998;157(1): 294-323.
20. Hickling KG. Best compliance during a decremental,but not
incremental,positive end-expiratory pressure trial is related to open-lung
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distress syndrome lungs. Am J Respir Crit Care Med,2001,163:69-78.
21. Gattinoni L, Caironi P, Cressoni M, et al. Lung recruitment in patients with
the acute respiratory distress syndrome. N Engl J Med
2006;354:1775-1786.
22. Borges JB, Okamato VN, Matos GFJ,et al. Reversibility of Lung Collapse
and Hypoxemia in Ea rly Acute Respiratory Distress Syndrome. Am J
Respir Crit Care Med 2006;174:268-278.
23. Girgis K, Hamed H, Khater Y et al . A decremental PEEP trial identifies the
PEEP level that maintains oxygenation after lung recruitment. Respir Care
2006; 51: 1132-9.
24. Dyhr T, Laursen N, Larsson A. Effects of lung recruitment maneuver and
positive end-expiratory pressure on lung volume, respiratory mechanics
and alveolar gas mixing in patients ventilated after cardiac surgery. Acta
Anaesthesiol Scand 2002; 46: 717-25.
25. Dyhr T, Bonde J , Larsson A. Lung recruitment manoeuvres are effective in
regaining lung volume and oxygenation after open endotracheal suctioning
in acute respiratory distress syndrome., Crit Care 2003; 7: 55-62.
26. Grasso S, Fanelli V, Cafarelli A, Anaclerio R et al. Effects of High versus
Low Positive End-Expiratory Pressures in Acute Respiratory Distress
Syndrome. Am J Respir Crit Care Med 2005;171:1002-1008.
27. Lapinsky SE, Aubin M, Mehta S, et al. Safety and efficacy of a sustained
inflation for alveolar recruitment in adults with respiratory failure.

58

Intensive Care Med 1999; 25: 12971301.

28. Lapinsky SE, Aubin M, Mehta S, et al. Safety and efficacy of a sustained
inflation for alveolar recruitment in adults with respiratory failure.
Intensive Care Med 1999; 25: 12971301.
29. Villagra A, Ochagavia A, Vatua S, et al. Recruitment maneuvers during
lung protective ventilation in acute respiratory distress syndrome. Am J
Respir Crit Care Med 2002; 165: 165170.
30. Oczenski W, Hormann C, Keller C, et al, Recruitment maneuvers after a
positive end-expiratory pressure trial do not induce sustained effects in
early adult respiratory distress syndrome. Anesthesiology
2004;101:620-650.
31. Medoff BD, Harris RS, Kesselman H et al. Use of recruitment maneuvers
and high-positive end-expiratory pressure in a patient with acute respiratory
distress syndrome. Crit Care Med, 2000; 28: 1210-6.
32. Bugedo G, Bruhn A, Hernandez G, et al. Lung computed tomography
during a lung recruitment maneuver in patient with acute lung injury.
Intensive Care Med 2003;29:218-225.
33. Lachmann B. Open up the lung and keep the lung open. Intensive Care
Med 1992;18:319-321.
34. Barbas CSV, de Matos GFJ, Pincelli MP, et al, Mechanical ventilation in
acute respiratory failure: recruitment and high positive end-expiratory
pressure are necessary., Curr Opin Crit Care 2005; 11: 18-28.
35. Pelosi P, Cadringher P, Bottino N, et al. Sigh in acute respiratory distress
syndrome. Am J Respir Crit Care Med 1999; 159: 872-880.
36. Lim CM, Jung H, Koh Y, et al. Effect of alveolar recruitment maneuver in
early acute respiratory distress syndrome according to antiderecruitment
strategy, etiological category of diffuse lung injury, and body position of

59

the patient. Crit Care Med 2003;31:411-418.

37. Meade MO, Cook DJ, Guyatt GH, et al. Ventilation strategy using low tidal
volumes, recruitment maneuvers, and high positive end-expiratory pressure
for acute lung injury and acute respiratory distress syndrome: a randomized
controlled trial. JAMA. 2008;13;299:637-45.
38. Grasso S, Mascia L, Del Turco M, et al. Effects of recruiting maneuvers in
patients with acute respiratory distress syndrome ventilated with protective
ventilatory strategy. Anesthesiology 2002; 96: 795802.
39. Mercat A, Richard J-C M, Vielle B et al. Positive End-Expiratory Pressure
Setting in Adults With Acute Lung Injury and Acute Respiratory Distress
Syndrome: A Randomized Controlled Trial. JAMA 2008; 299: 646-655.
40. MachIntyre N. Is there a best way to set positive expiratoryend Pressure
for mechanical ventilatory support in acute lung injury? Clin Chest Med
2008;29:233-239.
41. Levy MM. Optimal peep in ALI / ARDS changing concepts and current
controversies. Critical Care Clinics.2002;18:15-33.
42. Caironi P, Langer T, Gattinoni L. Acute lung injury/acute respiratory
distress syndrome pathophysiology: what we have learned from computed
tomography scanning. Curr Opin Crit Care 2008; 14:64-69.
43. Villar J, Kacmarek RM, Perez-Mendez L, et al. A high positive
end-expiration pressure, lowtidal volume ventilatory strategy improves
outcome in persistent acute respiratory distress syndrome: a randomized,
controlled trial. Critical Care Medicine 2006;34: 13111318.
44. Mergoni M,Volip A, Bricchi C, et al. Lower inflection point and
recruitment with PEEPin ventilated patients with acute respiratory failure. J
Appl Physiol 2001;91:441-450.
45 Talmor D, Sarge T, Malhotra A, O'Donnell CR, Ritz R, Lisbon A, Novack
V, Loring SH. Mechanical Ventilation Guided by Esophageal Pressure in

60

Acute Lung Injury. N Engl J Med 2008;359:2095-2104.

61

(Airway Pressure Release

Ventilation, APRV)
Series

Article title

Huang CC et al.

Effects of inverse ratio ventilation versus

20011

positive end-expiratory pressure on gas

exchange and gastric intramucosal PCO(2) and

Evidence
level

1-

pH under constant mean airway pressure in

acute respiratory distress syndrome.
Varpula T et al.

Airway pressure release ventilation as a

20042

primary ventilatory mode in acute respiratory

1+

distress syndrome
Putensen C et al.

Long-term effects of spontaneous breathing

200114

during ventilatory support in patients with acute

1+

lung injury.
Putensen C et al.

Spontaneous breathing during ventilatory

19993

support improves ventilation-perfusion

distributions in patients with acute respiratory

1+

distress syndrome.
Kaplan LJ et al.

Airway pressure release ventilation increases

20014

cardiac performance in patients with acute lung

2-

injury/adult respiratory distress syndrome.

Wrigge H et al.

Cardiorespiratory effects of automatic tube

20015

compensation during airway pressure release

2-

ventilation in patients with acute lung injury.

62

Varpula T, et al.

Airway pressure release ventilation as a

20047

primary ventilatory mode in acute respiratory

1+

distress syndrome.
Wrigge H et al.

Spontaneous breathing improves lung aeration

20038

in oleic acid-induced lung injury.

2-

Seymour CW et al. Airway pressure release and biphasic

200711

intermittent positive airway pressure

2++

ventilation: Are they ready for prime time?

Neumann P et al.

Influence of different release times on

200212

spontaneous breathing pattern during airway

2+

pressure release ventilation.

Gore DC.

Hemodynamic and ventilatory effects

199813

associated with increasing inverse

2-

inspiratory-expiratory ventilation.

63

(Airway Pressure Release

Ventilation, APRV)
1. Downs JB, Stock MC. Airway pressure release ventilation: a new concept
in ventilatory support. Crit Care Med 1987; 15:459461.
2. Huang CC, Shih MJ, Tsai YH, et al. Effects of inverse ratio ventilation
versus positive end-expiratory pressure on gas exchange and gastric
intramucosal PCO(2) and pH under constant mean airway pressure in acute
respiratory distress syndrome. Anesthesiology. 2001;95:1182-8.
3. Putensen C, Zech S, Wrigge H, et al. Long-term effects of spontaneous
breathing during ventilatory support in patients with acute lung injury. Am
J Respir Crit Care Med 2001; 164:4349.
4. Kaplan LJ, Bailey H, Formosa V. Airway pressure release ventilation
increases cardiac performance in patients with acute lung injury/adult
respiratory distress syndrome. Critical Care. 2001; 5:221-226.
5. Wrigge H, Zinserling J, Hering R, et al. Cardiorespiratory effects of
automatic tube compensation during airway pressure release ventilation in
patients with acute lung injury. Anesthesiology 2001; 95:382389.
6. Valentine DD, Hammond MD, Downs JB, et al. Distribution of ventilation
and perfusion with different modes of mechanical ventilation. Am Rev
Respir Dis 1991; 143:12621266.
7. Varpula T, Valta P, Niemi R, et al. Airway pressure release ventilation as a
primary ventilatory mode in acute respiratory distress syndrome. Acta
Anaesthesiol Scand 2004; 41:722-731.
8. Wrigge H, Zinserling J, Neumann P, et al. Spontaneous breathing improves
lung aeration in oleic acid-induced lung injury. Anesthesiology. 2003;
99:376-384.

64

9. Burchardi H. New strategies in mechanical ventilation for acute lung

injury. Eur Respir J 1996; 9:10631072.
10. Rathgeber J, Schorn B, FalkV, et al. The influence of controlled mandatory
ventilation (CMV), intermittent mandatory ventilation (IMV) and biphasic
intermittent positive airway pressure(BIPAP) on duration of intubation and
consumption of analgesics and sedatives: a prospective analysis in 596
patients following adult cardiac surgery. Eur J Anaesthesiol 1997;
14:576-582.
11. Seymour CW, Frazer M, Reilly PM, et al. Airway pressure release and
biphasic intermittent positive airway pressure ventilation: Are they ready
for prime time? J Trauma 2007;62:1298-1309.
12. Neumann P, Golisch W, Strohmeyer A, et al. Influence of different release
times on spontaneous breathing pattern during airway pressure release
ventilation. Intensive Care Medicine. 2002; 28(12):1742-9.
13. Gore DC. Hemodynamic and ventilatory effects associated with increasing
inverse inspiratory-expiratory ventilation. J Trauma. 1998;45:268-72
14. Putensen C, Norbert JM, Putensen-Himmer G, et al. Spontaneous breathing
during ventilatory support improves ventilation-perfusion distributions in
patients with acute respiratory distress syndrome. Am J Respir Crit Care
Med 1999; 159:12411241.

65



3.1

Petty

1.

Ashbaugh
19671

2.

3.
4. X
5.

Murray 1988
2

AECC 1994
3

1.

2.

3.

Non-pulmonary organ

dysfunction

1.

2. X

3. 18mmHg

4. PaO2/FiO2300

5. PaO2/FiO2200

66

 3.2 Murray JF (ARRD; 1988:138:720)

X

PEEP

5 cmH2O

1/4

6-8 cmH2O

2/4

9-11 cmH2O

3/4

12-14 cmH2O

4/4

15 cmH2O

PaO2/FiO2 300

80 ml / cmH2O

PaO2/FiO2 225-299

60-79 ml / cmH2O

PaO2/FiO2 175-224

40-59 ml / cmH2O

PaO2/FiO2 100-174

20-39 ml / cmH2O

PaO2/FiO2 100

19 ml / cmH2O

0.1-2.5

2.5

67

 3.3

68

 3.1 ARDS

7 10

Katzenstein
AA,

Askin FB. Surgical pathology of non-neoplastic lung disease. Sunders,

Philudelphia, 1982

69

 (protective lung strategy)

4.1 ALI/ALI / ARDS- low tidal volume/limit plateau pressure
Amato,19982
(n=53)

Brochard,19984
(n=116)

Stewart,19986
(n=120)

Brower,19995
(n=52)

ALI / ARDS
network,20003
(n=861)

Villar,20067
(n=103)

/
ALI/ALI / ARDS

LISS

LISS

NAECC

NAECC

PaO2/FiO2200mmHg

APACHE

33vs36
28vs27

57vs56
18vs17

PaO2/FiO2
250mmHg
59vs58
22vs21

51vs52
41vs52
81vs84APACHE 18vs18

PaO2/FiO2
/

Pplataucm H2O
PIPcm H2O
VtmL/kg

112 vs134

144 vs155

123 vs145

47vs50
90vs85
APACHE
129 vs150

20 vs
40 vs
a
6 vs
12normocapnia
2 above LIP vs titrated to best
PaO2/FiO2

(25-30) vs (60)

30 vs 45-55

30 vs 50

PaO2/FiO2200

SpaO2 89-93%

SpaO2 86-94%

SpaO2 88-95%

2 above LIP , 15cmH2O vs

5 cmH2O titrated to
SatO290%,PO270-100,
PaCO235-50 mmHg

Day1-7
range
Pplataucm H2O

23.9-31.8 vs 34.4-37.8

24.5-25.7 vs 30.5-31.7

20-22.3 vs26.8- 28.6

25 vs 31

25-26 vs 33-37

25.7-30.6 vs 32.4-32.6

PEEPcm H2O
VtmL or mL/kg
PaCO2cm H2O

13.2-16.4 vs6.9-9.3
387 vs 738 mL *
50.8-58.2 vs 33.2-35.7

9.6-10.7 vs 8.5-10.8
7 vs 10 mL/kg*
58.2-60 vs 41.3-41.7

8.6-9.6 vs 7.2-8.4
7 vs 11 mL/kg*
28-116(54) vs
29-72(46)

10 vs 9
7 vs 10 mL/kg*
50 vs 40

8.1-9.4 vs 8.6-9.1
6.2 vs 11.8 mL/kg*
40-44 s 35-40

8.2-14.1 vs 8.3-9.0
7.3 vs10.2 mL/kg*
41.7-42.9 vs
46.0-47.8

13/29 vs 17/24
.001
Bicarbonate if PH 7.20.
PV curve to set Vt and PEEP

27/58 vs 22/58
.38
Use of nitric oxide allowed
Bicarbonate if PH 7.05.

30/60 vs 28/60
.72
Bicarbonate if PH
7.00, or increased
ventilation if
refractory acidosis

13/26 vs 12/26
.38
Bicarbonate if PH 7.30

133/432 vs 170/429
.007
Increased ventilation if
PH 7.15

17/50 vs 25/45
.04
PV curve to set PEEP

NNT=12

NNT=5

PEEPcm H2O

(P value)

NNT=4

(6-10) vs
(10-15) normocapnia

30 vs50
c
8 vs (10-15) of IBW

8 vs (10-12) of IBW

138 vs134

6 vs 12 of IBW

139 vs 124

35-40 vs
d
5-8 vs9-11

LISS=Lung Injury Severity Score; NAECC=North American European Consensus Conference; IBW=ideal body weight; PIP=peak inspiratory pressure; Vt=tidal
volume; NNT/NNH=number needed to treat/number needed to harm; PEEP=positive end expiratory pressure; LIP=Lower inflection Point; PV=Pressure Volume;
PVC=Pressure controlled Ventilation. a:measured body weight
b:dry body weight c:ideal body weight d:predicted body weight,*P<0.01 In-hospital
mortality; Mortality before hospital discharge or at day 180; Mortality at day 6
70


5.1
FiO2%

30

PEEP(cmH2O) 5

40

50

60

70

80

5-8

8-10

10

10-14 14

90

100

14-18 18-24

71

 5.1

ALI / ARDS

ALI/ARDS
(-80 cm) 0.7
(-70 cm) 0.6

VC or PC (1)
VT 6-8 ml/kg
Pplat 30cmH2O

Pplat : 0.5
4 FiO2 / PEEP

FiO2 / PEEP
FiO2
PaO2

0.3
5

0.4
5-8

0.5

0.6

8-10

10

Hemodynamic Stable
( SBP 90) or BP decrease 20mmHg

PaO2 / FiO2300

PEEP FiO2
55PaO280 cmH2O,SpO2 90

Fluid challenge or Intropic agent

use

( PEEP 10 ) 2

: (3)
1. 18 75
2.
3.
4.
5. x bullae
6. 20 cmH2O
7.

RM I
CPAP 40cmH2O

Static
Pressure-volume loop
LIP UIP
sedation (Ramsay 6 )
paralyze

RM II
20cmH2O PEEP
with incremental PIP

RM III
P 15cmH2O with
incremental PEEP

72


6.1 ALI / ARDS Network

Low PEEP/ FiO2 Table

FiO2%

30

40

50

60

70

PEEP(cmH2O)

5-8

8-10

10

10-14 14

80

90

100

14-18 18-24

ALI / ARDS Network High PEEP/ FiO2 Table

FiO2%

30

40

PEEP(cmH2O)

5-14

14-16 16-18 20

50

50-80 80
22

90

100

22

22-24

73

 6.1 (I) RM: CPAP 40 cmH2O

CPAP 40 cmH2O40sec 3

,
1. SBP90mmHg, , SPO285%
2. HR20%60 `/
3.
Optimal PEEP
1. VC or PCV VT6-8 ml/kg, RR 10-12 pH7.25
2. FiO2 15-20 5-20% RM SpO2 90-94%
3. PEEP 20 cmH2O 5 2 cmH2O SpO290%
2 cmH2O
4. PEEP 20 cmH2O 5 2 cmH2O compliance
2 cmH2O
5.

RM
RM early stage ARDS 72 hrs
3-4 6-8 /
FiO20.4
PaO2+PaCO2400mmHg PaO2/FiO220% FiO2 100%
PaO2 60 mmHg Prone positionHFOV
Paralyze
ARDS

74

 6.2IIRM: 20cmH2O PEEP with incremental PIP

1. PCV mode , VT 6-8 ml/kg, RR12-15 /, I / E 1:1, FiO2 100%, PEEP

20 cmH2O
2. PEEP 20cmH2O,PIP PIP 50cmH2O,2min UIP+3

,
1 SBP90mmHg, , SPO288%
2 HR 20% 60 `/ Arrhythmia
3
Optimal PEEP
1. VC or PCV VT6-8 ml/kg, RR 12-15 I / E 1:2
2. FiO2 15-20 5-20% RM SpO2 90-94%
3. PEEP 20 cmH2O 5 2 cmH2O SpO290% 2
cmH2O
4. PEEP 20 cmH2O 5 2 cmH2O, compliance
2 cmH2O
5. 20

75

 6.3 ( III )

RM: P 15cmH2O with incremental PEEP

Basic Setting
Driving Pressure 15 cmH2O , VT 6-8 ml/kg, RR12-15 /, I / E 1:1
FiO2 100% PEEP 15 cmH2O
Step

15

15

15

15

15

15

15

15

PIP

35

30

40

30

45

30

50

35

PEEP

20

15

25

15

30

15

35

20

Time

end

,
1 SBP90mmHg, , SPO288%
2 HR 20% 60 `/ Arrhythmia
3

PCV mode , PIP 35cmH2O, RR12-15 /, I / E 1:2

FiO2 100%, PEEP 20 cmH2O Driving Pressure 15 cmH2O
5

PaO2+PaCO2400mmHg 5%
PIP 55-60 cmH2O Driving Pressure 15 cmH2O

Optimal PEEP
1. FiO2 15-20 5-20% RM SpO2 90-94%
2. PEEP 20 cmH2O 5 2 cmH2O SpO290%, 2
cmH2O
3. PEEP 20 cmH2O 5 2 cmH2O, compliance
2 cmH2O
4. 20
76

 6.2

ALI/ALI / ARDS(RM) -
Oczensk 200430

ALI / ARDS Network 200328

Meade200837

Lim 200336

Randomized control

Randomized crossover

Randomized control

Randomized control

Patient no.

30

96

983

47

age

66

5317

5616.5

61

Days of ALI / ARDS

3days

28 days

7days

LISS / PaO2/FiO2

PaO2/FiO2 200

PaO2/FiO2 300

PaO2/FiO2 250

LISS3.2

Baseline Mode

PC

VC

VC

V/C

VT

6 ml/kg

6 ml/kg

4-8 ml/kg

8 ml/kg

Baseline PEEP

8-20 cmH2O

High FiO2/PEEP table

(5-24 PEEP)

Ctrl: low FiO2/PEEP table

RM: high FiO2/PEEP table

10 cmH2O

Baseline Pplat

35 cmH2O

35 cmH2O

30 cmH2O

40 cmH2O

Recruitment

Sustained Pplat pressure 50

cmH2O,30s

RM CPAP 35-40 cmH2O,30s

CPAP 40 mH2O,40s4 times /

daily until FiO2 0.4

1ARM +PEEP15
2ARMPEEP 10
3PEEP 15
(ARM:extened sign 7min)

Complication

no

HRSPO2

BP SPO2
Barotrauma

No

RM response

PaO2/FiO2, Qs/Qt RM 3
30

RM Sham RM SPO2 60

(410 )FiO2/PEEP-step
240 Sham
RM RM

PaO2/FiO2,RM ,
,
(iNO,HFOV) RM

28

ARM +PEEP PaO2

1 ALI /
ARDS ALI / ARDS ,

ALI / ARDS
PEEPRM

RM

Open-lung

ARM PEEP ,
ARM
Prone

LISS:lung injury score, ARM: alveolar recruitment maneuver

77


7.1 APRV

P/V curve
upper inflection point Phigh
low inflection point Plow

T-PEFR(peak expiratory flow rate termination) > 50% and

< 75%
Thigh 4 - 6 Tlow 0.2 - 0.8
0.8 - 1.5

1. T-PEFR > 50% and < 75%

2. TlowT-PEFR 50%
3. Phigh
4. Phigh Thigh

1. T-PEFR 50 - 75%
2. T-PEFR 75% Tlow
T-PEFR 50%
3. Phigh
4. Phigh Thigh
5. Thigh Phigh

APRV
1. FiO2 < 0.5
2. 2 - 3 cm H2O PhighPlowP 8 ~ 12 cm H2O
3. IE PaCO2
4. CPAP PSV
Phigh 16 cm H2O
5. Thigh 12 - 15 (APRV = 90 % CPAP)

78