Giacomo Bellani, MD, PhDUniversity of Milan-Bicocca

A.O. San GerardoMonza (Italy)

Editorial view

@Gicobellani

Conflicts of Interest

INSTITUTIONAL: Research grants from:

– Draeger

– Maquet

– Airway Medix

– Chiesi Farmaceutica, SPA

Patent transferal to: Draeger

PERSONAL Consultancy fee from: Draeger

Lecturing fees: Draeger, GE, Pfizer

Co-owner and president of ReviewerCredits.com

SedationMuscle AtrophyHemodynamics

Better V/Q match

The dark side of spontaneousbreathing

Risk of high VtHigh inspiratory pressureAsynchroniesO2 Consumption

The bright side of spontaneous

breathing

Comment #2- inclusion criteriaModerate and severe ARDS

Civil war?

PaO2/FiO2

ACV

(n = 351)

BIPAP-APRV

(n = 346)

Baseline 133 (44) 137 (43)

Day 1 200 (77) 216 (120)

PaO2/FiO2

ACV

(n = 351)

BIPAP-APRV

(n = 346)

Baseline 133 (44) 137 (43)

0

10

20

30

40

50

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Spontaneous breathing(% Minute Ventilation)

mean + SD

Comment #3 - Was early Spont breathingreally achieved?

0

20

40

60

80

100

120

140

ACV BIPAP-APRV

mg

/day

Cisatracurium use

p = 0.014

0

50

100

150

200

250

300

350

400

ACV BIPAP-APRVm

g/d

ay

Cisatracurium use

Comment #4 - BIPAP and APRV

Pros: Decreased risk of non protective Vt Constant I:E (no breath stacking)

Cons: Modulation of patient effort rather tricky

Asynchronies +++

Conclusion

1. Congratulations! («editorial view» is an easy task…»)

2. Inclusion criteria

3. Was SB really achieved?

4. Subgroup analyses

1. Severe ARDS/mild ARDS

2. More/less «active» patients (dose response?)

5. Any benefit (or harm) for the diaphragm?