Inverse ratio ventilation

Inverse ratio ventilation (IRV) is not necessarily a mode of mechanical ventilation though it may be referred to as such. IRV is a strategy (method or style) of ventilating the lungs in such a way that the amount of time the lungs are in inhalation is greater than the amount of time they are in exhalation, allowing for a constant inflation of the lungs, ensuring they remain "recruited" (meaning they participate in gas exchange and are not allowed to deflate to get stuck together or tighten up). The primary goal for IRV is improved oxygenation by forcing inspiratory time to be greater than expiratory time (example: inhale is 3 seconds and exhalation is 1 second, a 3:1 I:E ratio) increasing the mean airway pressure and potentially improving oxygenation. Normal I:E ratio is 5:6, so forcing the I:E to be 2:1, 3:1, 4:1, (or even as high as 20:1) is the source of the term for the strategy.

IRV has not often been shown to improve important clinical outcomes, such as mortality, duration of mechanical ventilation, or duration of ICU stay. This may be due to the fact that IRV is not considered as a mode early enough once ARDS is diagnosed. The preponderance of evidence suggests that IRV improves oxygenation, although the evidence is weak and characterized by low quality, conflicting studies.[1][2][3][4][5][6][7][8][9][10][11][12]

Types

IRV can be performed during pressure-controlled ventilation (PC-IRV) or volume-controlled ventilation(VC-IRV). Neither is clearly superior to the other. In a multicenter, randomized trial that compared PC-IRV to VC-IRV in patients with acute respiratory distress syndrome, the type of IRV did not affect mortality.[13]

Associated risk

The shorter expiratory time during IRV increases the risk of auto-PEEP and its associated development of problems (e.g. pulmonary barotrauma, hypotension).[10] IRV also appears to increase the risk of pulmonary barotrauma independent of auto-PEEP. In a study of 14 patients undergoing mechanical ventilation with PC-IRV, the incidence of pneumothorax was 29 percent despite the lack of measurable auto-PEEP.[14]

Modes that utilize IRV

The most popular mode that utilizes IRV is the airway pressure release ventilation mode, also known by the brand name "BiVent". This employs an extremely high inverse ratio in a continuous pressure system similar to biphasic positive airway pressure but with several additional variables.

References
  1. Mercat A, Graïni L, Teboul JL, Lenique F, Richard C (1993). "Cardiorespiratory effects of pressure-controlled ventilation with and without inverse ratio in the adult respiratory distress syndrome". Chest. 104 (3): 871–5. doi:10.1378/chest.104.3.871. PMID 8365303.
  2. Mercat A, Diehl JL, Michard F, Anguel N, Teboul JL, Labrousse J, et al. (2001). "Extending inspiratory time in acute respiratory distress syndrome". Crit Care Med. 29 (1): 40–4. doi:10.1097/00003246-200101000-00011. PMID 11176158.
  3. Shanholtz C, Brower R (1994). "Should inverse ratio ventilation be used in adult respiratory distress syndrome?". Am J Respir Crit Care Med. 149 (5): 1354–8. doi:10.1164/ajrccm.149.5.8173778. PMID 8173778.
  4. Mercat A, Titiriga M, Anguel N, Richard C, Teboul JL (1997). "Inverse ratio ventilation (I/E = 2/1) in acute respiratory distress syndrome: a six-hour controlled study". Am J Respir Crit Care Med. 155 (5): 1637–42. doi:10.1164/ajrccm.155.5.9154869. PMID 9154869.
  5. Wang SH, Wei TS (2002). "The outcome of early pressure-controlled inverse ratio ventilation on patients with severe acute respiratory distress syndrome in surgical intensive care unit". Am J Surg. 183 (2): 151–5. doi:10.1016/s0002-9610(01)00870-4. PMID 11918879.
  6. Sydow M, Burchardi H, Ephraim E, Zielmann S, Crozier TA (1994). "Long-term effects of two different ventilatory modes on oxygenation in acute lung injury. Comparison of airway pressure release ventilation and volume-controlled inverse ratio ventilation". Am J Respir Crit Care Med. 149 (6): 1550–6. doi:10.1164/ajrccm.149.6.8004312. PMID 8004312.
  7. Abraham E, Yoshihara G (1989). "Cardiorespiratory effects of pressure controlled inverse ratio ventilation in severe respiratory failure". Chest. 96 (6): 1356–9. doi:10.1378/chest.96.6.1356. PMID 2582844.
  8. Amato MB, Barbas CS, Medeiros DM, Schettino Gde P, Lorenzi Filho G, Kairalla RA, et al. (1995). "Beneficial effects of the "open lung approach" with low distending pressures in acute respiratory distress syndrome. A prospective randomized study on mechanical ventilation". Am J Respir Crit Care Med. 152 (6 Pt 1): 1835–46. doi:10.1164/ajrccm.152.6.8520744. PMID 8520744.
  9. Gurevitch MJ, Van Dyke J, Young ES, Jackson K (1986). "Improved oxygenation and lower peak airway pressure in severe adult respiratory distress syndrome. Treatment with inverse ratio ventilation". Chest. 89 (2): 211–3. doi:10.1378/chest.89.2.211. PMID 3943380. S2CID 41234021.
  10. Tharratt RS, Allen RP, Albertson TE (1988). "Pressure controlled inverse ratio ventilation in severe adult respiratory failure". Chest. 94 (4): 755–62. doi:10.1378/chest.94.4.755. PMID 3168572. S2CID 20053045.
  11. Papadakos PJ, Halloran W, Hessney JI, Lund N, Feliciano DV (1991). "The use of pressure-controlled inverse ratio ventilation in the surgical intensive care unit". J Trauma. 31 (9): 1211–4, discussion 1214–5. doi:10.1097/00005373-199109000-00003. PMID 1920550.
  12. Lain DC, DiBenedetto R, Morris SL, Van Nguyen A, Saulters R, Causey D (1989). "Pressure control inverse ratio ventilation as a method to reduce peak inspiratory pressure and provide adequate ventilation and oxygenation". Chest. 95 (5): 1081–8. doi:10.1378/chest.95.5.1081. PMID 2495904.
  13. Esteban A, Alía I, Gordo F, de Pablo R, Suarez J, González G, et al. (2000). "Prospective randomized trial comparing pressure-controlled ventilation and volume-controlled ventilation in ARDS. For the Spanish Lung Failure Collaborative Group". Chest. 117 (6): 1690–6. doi:10.1378/chest.117.6.1690. PMID 10858404. S2CID 42343728.
  14. Armstrong BW, MacIntyre NR (1995). "Pressure-controlled, inverse ratio ventilation that avoids air trapping in the adult respiratory distress syndrome". Crit Care Med. 23 (2): 279–85. doi:10.1097/00003246-199502000-00013. PMID 7867353.
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