Close Down the Lungs and Keep them Resting to Minimize Ventilator-induced Lung Injury

Pelosi, Paolo; Rocco, Patrícia Rieken Macêdo; Abreu, Marcelo Gama de

doi:10.1007/978-3-319-73670-9_18

Cited by 3 publications

(3 citation statements)

References 47 publications

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“…However, PaO 2 /FiO 2 depends on FiO 2 and PEEP levels affect cardiac output (CO). Recently, the concept of "keeping the lung at rest with permissive atelectasis and minimal oxygenation targets" has been proposed [49]. Oxygen consumption (VO 2 ) is dependent on oxygen delivery (DO 2 ); consequently, maximizing DO 2 might be considered an alternative therapeutic goal for managing ARDS patients [50,51].…”

Section: Targeting Gas Exchangementioning

confidence: 99%

Personalized mechanical ventilation in acute respiratory distress syndrome

et al. 2021

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A personalized mechanical ventilation approach for patients with adult respiratory distress syndrome (ARDS) based on lung physiology and morphology, ARDS etiology, lung imaging, and biological phenotypes may improve ventilation practice and outcome. However, additional research is warranted before personalized mechanical ventilation strategies can be applied at the bedside. Ventilatory parameters should be titrated based on close monitoring of targeted physiologic variables and individualized goals. Although low tidal volume (VT) is a standard of care, further individualization of VT may necessitate the evaluation of lung volume reserve (e.g., inspiratory capacity). Low driving pressures provide a target for clinicians to adjust VT and possibly to optimize positive end-expiratory pressure (PEEP), while maintaining plateau pressures below safety thresholds. Esophageal pressure monitoring allows estimation of transpulmonary pressure, but its use requires technical skill and correct physiologic interpretation for clinical application at the bedside. Mechanical power considers ventilatory parameters as a whole in the optimization of ventilation setting, but further studies are necessary to assess its clinical relevance. The identification of recruitability in patients with ARDS is essential to titrate and individualize PEEP. To define gas-exchange targets for individual patients, clinicians should consider issues related to oxygen transport and dead space. In this review, we discuss the rationale for personalized approaches to mechanical ventilation for patients with ARDS, the role of lung imaging, phenotype identification, physiologically based individualized approaches to ventilation, and a future research agenda.

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Section: Targeting Gas Exchangementioning

confidence: 99%

Personalized mechanical ventilation in acute respiratory distress syndrome

et al. 2021

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“…The optimal methodology of RM is arguable and, probably, as in the case of PEEP, should be associated with the decrease of both pulmonary pressures and V T ; otherwise, despite improved oxygenation, increased pressures can contribute to static lung injury [14]. The conflicts between the potential benefits of RM and high PEEP versus increased risk of 'static' lung injury resulting in VALI prompted Pelosi et al [66] to declare a new striking motto: 'Close down the lungs and keep them resting' 25 years after the original concept by Lachmann [67] (1992): 'Open up the lung and keep the lung open. ' The controversial effects of RM and high PEEP on pulmonary edema and systemic hemodynamics, the evidence of reduced injury and inflammation in the collapsed regions, the risk of static strain and overdistension, and even the emerging concept of 'permissive atelectases' support the position that we should personalize an 'open lung approach' only to the subsets of responders with significant and proven recruitment potential [68,69].…”

Section: Alveolar Recruitment and Open Lung Approach: Not For Everyone?mentioning

confidence: 99%

Protective ventilation from ICU to operating room: state of art and new horizons

Kirov

Kuzkov

2020

Korean J Anesthesiol

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The prevention of ventilator-associated lung injury (VALI) and postoperative pulmonary complications (PPC) is of paramount importance for improving outcomes both in the operating room and in the intensive care unit (ICU). Protective respiratory support includes a wide spectrum of interventions to decrease pulmonary stress-strain injuries. The motto 'low tidal volume for all' should become routine, both during major surgery and in the ICU, while application of a high positive end-expiratory pressure (PEEP) strategy and of alveolar recruitment maneuvers requires a personalized approach and warrants further investigation. Patient self-inflicted lung injury is an important type of VALI, which should be diagnosed and mitigated at the early stage, during restoration of spontaneous breathing. This narrative review highlights the strategies used for protective positive pressure ventilation. The emerging concepts of damaging energy and power, as well as pathways to personalization of the respiratory settings, are discussed in detail. In the future, individualized approaches to protective ventilation may involve multiple respiratory settings extending beyond low tidal volume and PEEP, implemented in parallel with quantifying the risk of VALI and PPC.

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“…From a scientific viewpoint, the study offers perspectives for further investigation, highlighting the concept of permissive atelectasis, that is, the potential of lung rest to protect from ventilator-induced lung injury. 13 Even more relevant are the clinical implications of this study. When interpreted together with other trials, [4][5][6] this subanalysis emphasizes the concept of "first, do no harm."…”

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confidence: 93%