Is spontaneous breathing preferable during acute respiratory distress syndrome?

Abstract

Preservation of spontaneous breathing during acute respiratory distress syndrome (ARDS), whether by using the pressure support ventilation, the biphasic airway pressure (BiPAP® or Bilevel), or the airway pressure release ventilation could provide some benefits regarding hemodynamics, prevention of diaphragmatic dysfunction, decrease of both the duration of intensive care unit stay and duration of mechanical ventilation. However, in the most severe forms of ARDS, during the acute phase, recent studies have shown a reduction in mortality due to a short duration use of neuromuscular blocking agents as well as prone positioning, arguing for a limitation or an abolition of the spontaneous breathing during the peak of the lung injury to promote a protective ventilation. Based on the evidence available in the literature, this review aims to show the benefits of maintaining spontaneous ventilation in ARDS, while emphasizing its limitations and risks for lung parenchyma.We define a sequential strategy of ventilatory management based on the severity of ARDS and its evolution, i.e. a protective ventilation with the abolition of spontaneous efforts using neuromuscular blocking agents at the acute and more severe phase, followed by the restoration of spontaneous breathing. These two strategies are therefore complementary in the ventilatory management of patients with severe ARDS.