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P–V Approach Revisited

Ullrich, Roman M.D.; Germann, Peter M.D.

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In Reply:—
We appreciate the interest expressed by Drs. Pestel and Rothhammer with regard to our recent article. 1 Although pressure-controlled ventilation with positive end-expiratory pressure is an integral component of our treatment algorithm, we did not measure pressure–volume curves of the lungs, but rather set the values of positive end-expiratory pressure and peak inspiratory pressure according to previous clinical studies. 2,3 Therefore, no inference can be made from our findings about the feasibility or clinical value of setting ventilatory pressure limits according to measures of pressure–volume curves in patients with acute respiratory distress syndrome.
In addition, we emphasize that we cannot take credit for “the desired impact on ventilatory strategy in critical care units” because this goal has been achieved by others in large, randomized clinical trials. 4,5 Our study, however, provides evidence for an additional hypothesis; namely, that a combined treatment strategy, including the best available conventional management protocol and extracorporeal membrane oxygenation results in an improved survival rate for patients with acute respiratory distress syndrome.
Roman Ullrich M.D.
Peter Germann M.D.
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1. Ullrich R, Lorber C, Röder G, Urak G, Faryniak B, Sladen RN, Germann P: Controlled airway pressure therapy, nitric oxide inhalation, prone position, and extracorporeal membrane oxygenation (ECMO) as components of an integrated approach to ARDS. A nesthesiology 1999; 91: 1577–86

2. East TD, Boehm SH, Wallace CJ, Clemmer TP, Weaver LK, Orme JF Jr, Morris AH: A successful computerized protocol for clinical management of pressure control inverse ratio ventilation in ARDS patients. Chest 1992; 101: 697–710

3. Germann P, Pöschl G, Leitner C, Urak G, Ullrich R, Faryniak B, Röder G, Kaider A, Sladen R: Additive effect of nitric oxide inhalation on the oxygenation benefit of the prone position in the adult respiratory distress syndrome. A nesthesiology 1998; 89: 1401–6

4. Amato MBP, Barbas CSV, Medeiros DM, Magaldi RB, Schettino GDP, Lorenzi G, Kairalla RA, Deheinzelin D, Munoz C, Oliveira R, Takagaki TY, Larvalho CRR: Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 1998; 338: 347–54

5. The Acute Respiratory Distress Syndrome Network: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med [serial online]. March 10, 2000

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