In the fluid-filled lungs of early
adult respiratory distress syndrome (ARDS) the dependent parts are compressed and atelectatic; whereas, the nondependent areas remain aerated and functional. Ventilating these considerably restricted lungs carries the risk of overinflation and ventilatory-induced
lung injury (baro-volutrauma). The consequences for adjusting
mechanical ventilation are: 1) reducing tidal volumes in order to avoid alveolar hyperinflation and excessive alveolar pressures; 2) considering permissive
hypercapnia if adequate CO2 elimination cannot be maintained; 3) keeping open the unstable alveoli by
positive end-expiratory pressure (PEEP) (external or intrinsic). However, the large variations in regional lung compliance make it improbable that an optimal external PEEP level beneficial for the whole lung will be found; 4) using
intrinsic PEEP in the inverse ratio ventilation (IRV) mode which varies with differences in regional ventilatory kinetics. No clinical study has yet convincingly demonstrated the benefit of IRV compared to conventional ventilation, controlled clinical long-term trials are not yet available; and 5) using superimposed spontaneous breathing which may be considerably more effective in opening up collapsed alveoli, combined with intentional
intrinsic PEEP this is achieved in
airway pressure release ventilation (APRV). Other new principles of
mechanical ventilation, such as "
proportional assist ventilation" or "tracheal gas insufflation" must still be considered as experimental.