We thank Drs. Dongelmans and Schultz for their letter expressing interest in our recent publication on adaptive support ventilation (ASV).1
They correctly describe how ASV works but indicate that the ability of ASV to vary tidal volume in response to a changing clinical presentation is of concern especially if the tidal volume is allowed to exceed 6 ml/kg.
First, it is important to remember that the tidal volumes used by the Acute Respiratory Distress Syndrome Network2
in its landmark study varied between 4 and 8 ml/kg. Indeed, as we showed in our study, even though the average tidal volume delivered to patients in the low-tidal volume arm was about 6 ml/kg, tidal volume did vary between 4 and 8 ml/kg in many patients.
We believe that allowing tidal volume to increase while keeping plateau pressure at a minimum setting (<28 cm H2
O in our study) is the major concern of Drs. Dongelmans and Schultz, and they reference Hager et al.3
to demonstrate their point. However, they failed to acknowledge the subsequent letter from Shiu and Rozen4
who determined from Hager's data that no significant change in mortality was observed regardless of tidal volume once plateau pressure was less than 28 cm H2
O. Drs. Dongelmans and Schultz also referred to the article by Gajic et al
which was a retrospective review with plateau pressures available on only a few patients to illustrate the potential of large tidal volumes causing acute lung injury. The tidal volume range applied by ASV is essentially within the range of the lowest risk group (≤9 ml/kg) in the article by Gajic et al
In addition, there are numerous articles in the surgical literature that indicate that at least short-term application of large tidal volume does not result in lung injury6–10
in patients without existing lung injury. As we noted in our discussion, the upper and lower limits on ASV may need to be adjusted, and we believe that the upper limit should be set for patients with acute lung injury or acute respiratory distress syndrome at 8 ml/kg. However, the concept of ASV is sound because if practitioners are left on their own to adjust tidal volume, even centers who participated in the Acute Respiratory Distress Syndrome Network trial do not always appropriately select low tidal volumes and plateau pressures.11
Where we believe the concept of ASV is most critical is in the patient where in spite of tidal volume being set at 6 ml/kg, plateau pressure exceeds 28 cm H2
O. It is very clear that in these patients, the risk of increased mortality is real.3,12
ASV does in these patients what the clinician should do and that is to reduce the tidal volume to avoid overdistension. ASV may not have the absolute limits correct, but the concept of closed loop control of ventilation is the future!
Demet S. Sulemanji, M.D.
Robert M. Kacmarek, Ph.D., R.R.T.*
*Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. firstname.lastname@example.org
1.Sulemanji D, Marchese A, Garbarini P, Wysocki M, Kacmarek RM: Adaptive support ventilation: An appropriate mechanical ventilation strategy for acute respiratory distress syndrome? Anesthesiology 2009; 111:863–70
2.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 Eng J Med 2000; 342:1301–8
3.Hager DN, Fessler HE, Kaczka DW, Shanholtz CB, Fuld MK, Simon BA, Brower RG: Tidal volume delivery during high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome. Crit Care Med 2007; 35:1522–9
4.Shiu KK, Rozen MJ: Is there a safe plateau pressure threshold for patients with acute lung injury and the acute respiratory distress syndrome? (letter) Am J Respir Crit Care Med 2006; 173:686
5.Gajic O, Dara SI, Mendez JL, Adesanya AO, Festic E, Caples SM, Rana R, St Sauver JL, Lymp JF, Afessa B, Hubmayr RD: Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation. Crit Care Med 2004; 32:1817–24
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7.Wrigge H, Uhlig U, Zinserling J, Behrends-Callsen E, Ottersbach G, Fischer M, Uhlig S, Putensen C: The effects of different ventilatory settings on pulmonary and systemic inflammatory responses during major surgery. Anesth Analg 2004; 98:775–81
8.Koner O, Celebi S, Balci H, Cetin G, Karaoglu K, Cakar N: Effects of protective and conventional mechanical ventilation on pulmonary function and systemic cytokine release after cardiopulmonary bypass. Intensive Care Med 2004; 30:620–6
9.Wrigge H, Zinserling J, Stüber F, von Spiegel T, Hering R, Wetegrove S, Hoeft A, Putensen C: Effects of mechanical ventilation on release of cytokines into systemic circulation in patients with normal pulmonary function. Anesthesiology 2000; 93:1413–7
10.Lee PC, Helsmoortel CM, Cohn SM, Fink MP: Are low tidal volumes safe? Chest 1990; 97:430–4
11.Kahn JM, Rubenfeld GD: Translating evidence into practice in the intensive care unit: The need for a systems based approach. J Crit Care 2005; 20:204–6
12.Petrucci N, Iacovelli W: Ventilation with lower tidal volumes versus traditional tidal volumes in adults for acute lung injury and acute respiratory distress syndrome. Cochrane Database Syst Rev 2003; 3:CD003844
© 2010 American Society of Anesthesiologists, Inc.