Management of primary blast lung injury: a comparison of airway pressure release versus low tidal volume ventilation

Scott, Timothy E.; Das, Anup; Haque, Mainul; Bates, Declan G.; Hardman, Jonathan G.

Abstract

Background

Primary blast lung injury (PBLI) presents as a syndrome of respiratory distress and haemoptysis resulting from explosive shock wave exposure and is a frequent cause of mortality and morbidity in both military conflicts and terrorist attacks. The optimal mode of mechanical ventilation for managing PBLI is not currently known, and clinical trials in humans are impossible due to the sporadic and violent nature of the disease.

Methods

A high-fidelity multi-organ computational simulator of PBLI pathophysiology was configured to replicate data from 14 PBLI casualties from the conflict in Afghanistan. Adaptive and responsive ventilatory protocols implementing low tidal volume (LTV) ventilation and airway pressure release ventilation (APRV) were applied to each simulated patient for 24 h, allowing direct quantitative comparison of their effects on gas exchange, ventilatory parameters, haemodynamics, extravascular lung water and indices of ventilator-induced lung injury.

Results

The simulated patients responded well to both ventilation strategies. Post 24-h investigation period, the APRV arm had similar PF ratios (137 mmHg vs 157 mmHg), lower sub-injury threshold levels of mechanical power (11.9 J/min vs 20.7 J/min) and lower levels of extravascular lung water (501 ml vs 600 ml) compared to conventional LTV. Driving pressure was higher in the APRV group (11.9 cmH2O vs 8.6 cmH2O), but still significantly less than levels associated with increased mortality.

Conclusions

Appropriate use of APRV may offer casualties with PBLI important mortality-related benefits and should be considered for management of this challenging patient group.

Citation

Scott, T. E., Das, A., Haque, M., Bates, D. G., & Hardman, J. G. (2020). Management of primary blast lung injury: a comparison of airway pressure release versus low tidal volume ventilation. Intensive Care Medicine Experimental, 8(1), Article 26. https://doi.org/10.1186/s40635-020-00314-2

• Journal Article Type: Article
• Acceptance Date: Jun 4, 2020
• Online Publication Date: Jun 23, 2020
• Publication Date: 2020-12
• Deposit Date: Jun 16, 2020
• Publicly Available Date: Jul 3, 2020
• Journal: Intensive Care Medicine Experimental
• Electronic ISSN: 2197-425X
• Publisher: Springer Verlag
• Peer Reviewed: Peer Reviewed
• Volume: 8
• Issue: 1
• Article Number: 26
• DOI: https://doi.org/10.1186/s40635-020-00314-2
• Public URL: https://nottingham-repository.worktribe.com/output/4659542
• Publisher URL: https://icm-experimental.springeropen.com/articles/10.1186/s40635-020-00314-2
• Additional Information: Received: 4 March 2020; Accepted: 4 June 2020; First Online: 23 June 2020; : The study was conducted entirely in silico and did not involve human or animal participation.; : The manuscript contains no personal or otherwise sensitive data.; : We have no competing interests to declare.