• C Pichot, A Picoche, M I Saboya-Steinbach, R Rousseau, J de Guys, M Lahmar, D Thomas, M Guerry, J M Lalot, R Monarchi, M Galliez, M Ghignone, and L Quintin.
• Critical Care, Epinal Hospital, Epinal, France.
• Acta Anaesthesiol Belg. 2012 Jan 1;63(3):127-33.

IntroductionAs alpha-2 agonists preserve ventilator drive, patients presenting with acute respiratory distress syndrome (ARDS, Pa02/FiO2 < 200) were managed using sedation with an alpha-2 agonist, clonidine, combined to spontaneous ventilation (SV) + pressure support ventilation (PS).MethodsSedation was provided by an alpha-2 agonist, clonidine 1-2 microg x kg(-1( x h(-1), without bolus administration, and supplemented with a neuroleptic, loxapine, if needed. Four patients presenting with ARDS were managed with pressure support ventilation (PS = 8 cm H20,rarely 10-12 cm H20) and high PEEP (10-20 cm H20). Energy requirements were minimized, if appropriate, with hypothermia caused by extra-renal replacement therapy or intentional hypothermia (35-36 degrees C). Repeated echocardiographic examinations revealed no right ventricular failure.ResultsRecovery of ARDS, i.e. sustained increase of P/F > 200 for > 24 h, was observed, over 2-5 days.ConclusionUse of an alpha-2 agonist as first-line sedative agent led to absence of respiratory depression and spontaneous ventilation. Upon ARDS, the lowered intrathoracic pressure observed with SV+PSV allowed one to recruit alveoli with high levels of PEEP, without impairing right ventricle function.

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