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• W2911640332 abstract "To the Editor: Our editorial was prompted by concerns that proponents of inverse ratio ventilation (IRV) did not appreciate, or insufficiently, appreciated, the high end-expiratory pressure almost certainly created by this modality. Particularly distressing was the potential for widespread therapeutic misadventure if this ventilatory technique was to be extensively used without due consideration of possible adverse sequelae. The history of medicine abounds with examples of popular but marginally useful or frankly deleterious therapies uncritically implemented after publication of anecdotal reports. Although Dr. Gurevitch may have been addressing the IRV augmentation of end-expiratory lung volumes (and pressures) for several years, this was by no means evident from the published data or other readily available information. His own published report foils to make mention of hyperinflation, auto-PEEP, or equivalent physiologic parameters.1Gurevitch MJ Van Dyke J Young ES Jackson K. Improved oxygenation and lower peak airway pressure in severe adult respiratory distress syndrome. Treatment with inverse ratio ventilation.Chest. 1986; 89: 211-213Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar Easily obtainable hemodynamic data were not systematically detailed (eg, cardiac outputs) or were conspicuously absent (eg, O2 delivery). The putative benefit of IRV was postulated to be due to “early and sustained insufflation”. In fairness, in a subsequent unpublished symposium, Dr. Gurevitch did mention in passing a “PEEP-like effect” with regard to improved gas exchange during IRV.2Gurevitch MJ. Inverse ratio ventilation. Presented at the symposium on experimental ventilation.Hollywood Presbyterian Medical Center. 1986; (October 24)Google Scholar It is arguable whether such a fleeting reference constituted an adequate discourse on this important concept. In any event, this information was much less widely disseminated than published reports. Dr. Gurevitch implores the use of caution when comparing volume-cycled IRV and pressure-controlled, time-cycled IRV. We are unable to conceive of a mechanism whereby inadequate expiratory time would not lead to auto-PEEP, irrespective of ventilator mode. At least two recent reports have demonstrated the production of significant auto-PEEP by IRV.3Conoscenti CS Menashe P Meduri GU Gottlieb J. Intrinsic PEEP during inverse ratio ventilation.Am Rev Respir Dis. 1987; 135: A55Google Scholar, 4Andersen JB. Inverse I:E ratio ventilation with pressure control in catastrophic lung disease in adults.Intensive Care World. 1987; 4: 21-23Google Scholar Both studies employed the pressure-controlled, time-cycled mode advocated by Dr. Gurevitch. As of yet unpublished data by one of these groups show little difference in auto-PEEP production between volume-cycled and time-cycled ventilation.5Menashe P, Conoscenti CS. (Personal communication)Google Scholar Similarly, it seems to make little difference whether auto-PEEP is quantitated by expiratory circuit occlusion using manual means (older, volume-cycled ventilators)6Pepe PE Marini JJ. Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction.Am Rev Respir Dis. 1982; 126: 166-170PubMed Google Scholar or by pressing a button (on newer ventilators with pressure support capabilities). The first step in the measurement of auto-PEEP is to think of it. The presence of auto-PEEP during IRV was not obviously contemplated—much less measured or reported—in earlier published studies (including that of Dr. Gurevitch). We are pleased that Dr. Gurevitch now believes auto-PEEP is an important operative mechanism of IRV and routinely quantitates pressures while using this modality. The need to do so was precisely the point of our editorial. Auto-PEEP is not necessarily evil but needs to be considered in determinations of gas exchange, hemodynamic variables, and pulmonary compliance. We suggest that future investigations systematically measure relevant intrathoracic pressures and hemodynamic parameters as well as clinical outcomes. The development of improved therapies (including ventilator techniques) is laudable. It is not always possible to predict adverse effects while conducting preliminary investigations. However, it is incumbent upon investigators to be aware of and to report, inasmuch as is possible, readily apparent confounding mechanisms and potentially harmful sequelae. Ventilatory SupportCHESTVol. 93Issue 5PreviewTo the Editor: Full-Text PDF" @default.
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• W2911640332 title "Ventilatory Support" @default.
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