Pressure-Controlled vs Volume-Controlled Ventilation in Acute Respiratory Failure

A Physiology-Based Narrative and Systematic Review
  • Nuttapol Rittayamai
    Affiliations
    Li Ka Shing Knowledge Institute and Critical Care Department, St. Michael's Hospital, Toronto, ON, Canada

    Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada

    Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
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  • Christina M. Katsios
    Affiliations
    Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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  • François Beloncle
    Affiliations
    Li Ka Shing Knowledge Institute and Critical Care Department, St. Michael's Hospital, Toronto, ON, Canada

    Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada

    Medical Intensive Care Unit, Hospital of Angers, Université d'Angers, Angers, France
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  • Jan O. Friedrich
    Affiliations
    Li Ka Shing Knowledge Institute and Critical Care Department, St. Michael's Hospital, Toronto, ON, Canada

    Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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  • Jordi Mancebo
    Affiliations
    Servei de Medicina Intensiva, Hospital Sant Pau, Barcelona, Spain
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  • Laurent Brochard
    Correspondence
    CORRESPONDENCE TO: Laurent Brochard, MD, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada
    Affiliations
    Li Ka Shing Knowledge Institute and Critical Care Department, St. Michael's Hospital, Toronto, ON, Canada

    Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada

    Keenan Research Centre, St. Michael's Hospital, Toronto, ON, Canada
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      BACKGROUND

      Mechanical ventilation is a cornerstone in the management of acute respiratory failure. Both volume-targeted and pressure-targeted ventilations are used, the latter modes being increasingly used. We provide a narrative review of the physiologic principles of these two types of breath delivery, performed a literature search, and analyzed published comparisons between modes.

      METHODS

      We performed a systematic review and meta-analysis to determine whether pressure control-continuous mandatory ventilation (PC-CMV) or pressure control-inverse ratio ventilation (PC-IRV) has demonstrated advantages over volume control-continuous mandatory ventilation (VC-CMV). The Cochrane tool for risk of bias was used for methodologic quality. We also introduced physiologic criteria as quality indicators for selecting the studies. Outcomes included compliance, gas exchange, hemodynamics, work of breathing, and clinical outcomes. Analyses were completed with RevMan5 using random effects models.

      RESULTS

      Thirty-four studies met inclusion criteria, many being at high risk of bias. Comparisons of PC-CMV/PC-IRV and VC-CMV did not show any difference for compliance or gas exchange, even when looking at PC-IRV. Calculating the oxygenation index suggested a poorer effect for PC-IRV. There was no difference between modes in terms of hemodynamics, work of breathing, or clinical outcomes.

      CONCLUSIONS

      The two modes have different working principles but clinical available data do not suggest any difference in the outcomes. We included all identified trials, enhancing generalizability, and attempted to include only sufficient quality physiologic studies. However, included trials were small and varied considerably in quality. These data should help to open the choice of ventilation of patients with acute respiratory failure.

      ABBREVIATIONS:

      APRV ( airway pressure release ventilation), ARF ( acute respiratory failure), CMV ( continuous mandatory ventilation), Crs ( respiratory system compliance), IMV ( intermittent mandatory ventilation), i:e ( inspiratory to expiratory), PC ( pressure control), PEEP ( positive end-expiratory pressure), PEEPi ( intrinsic positive end-expiratory pressure), P:F ( Pao2 to Fio2), PIP ( peak inspiratory pressure), PL ( transpulmonary pressure), Pplat ( plateau pressure), PSV ( pressure support ventilation), Te ( expiratory time), Ti ( inspiratory time), VC ( volume control), Vt ( tidal volume)
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