Patient-Self Inflicted Lung Injury: A Practical Review

Abstract

Patients with severe lung injury usually have a high respiratory drive, resulting in intense inspiratory effort that may even worsen lung damage by several mechanisms gathered under the name “patient-self inflicted lung injury” (P-SILI). Even though no clinical study has yet demonstrated that a ventilatory strategy to limit the risk of P-SILI can improve the outcome, the concept of P-SILI relies on sound physiological reasoning, an accumulation of clinical observations and some consistent experimental data. In this review, we detail the main pathophysiological mechanisms by which the patient’s respiratory effort could become deleterious: excessive transpulmonary pressure resulting in over-distension; inhomogeneous distribution of transpulmonary pressure variations across the lung leading to cyclic opening/closing of nondependent regions and pendelluft phenomenon; increase in the transvascular pressure favoring the aggravation of pulmonary edema. We also describe potentially harmful patient-ventilator interactions. Finally, we discuss in a practical way how to detect in the clinical setting situations at risk for P-SILI and to what extent this recognition can help personalize the treatment strategy.

A Successful Outcome of Veno-Venous Extracorporeal Membrane Oxygenation in Obese Patients with Respiratory Failure in the Course of COVID-19: A Report of Two Cases

“…On discharge from the ICU, both patients achieved between 70 and 80 points in the Barthel Index, which proves that the therapy was successful. In our two cases, ventilation during ECMO with decreased Pins and driving pressure reduced the potential risk of VILI [ 6 ].…”

“…The necessity of treating COVID-19 patients in the ICU is associated with a high probability of complications, such as severe respiratory failure, including acute respiratory distress syndrome (ARDS) or patient self-inflicted lung injury (P-SILI) [ 3 , 4 , 5 ]. In a small proportion of patients with severe respiratory failure, optimal mechanical ventilation does not provide adequate gas exchange and can lead to ventilator-induced lung injury (VILI) [ 6 ]. Despite the implementation of the recommended procedure, patients continue to experience persistent hypoxemia, in some cases with concomitant hypercapnia.…”

Advanced respiratory monitoring in mechanically ventilated patients with coronavirus disease 2019-associated acute respiratory distress syndrome

“…Adequate inspiratory effort is essential in the recovery of patients when weaning from respiratory support, but can be harmful for the injured lung. Patients with acute hypoxemic respiratory failure are at risk of developing P-SILI caused by extreme inspiratory efforts resulting in excessive stress aggravating existing lung injury [49][50][51]. Gattinoni et al [52 & ] and Battaglini et al [53] emphasize the importance of the respiratory drive and the risk of P-SILI in the development of C-ARDS.…”

Reverse Triggering: An Introduction to Diagnosis, Management, and Pharmacologic Implications

“…Careful management of this supportive care modality that minimizes iatrogenic harm poses a unique clinical challenge in the construct of balancing benefits and harms. While some aspects of VILI (i.e., use of injurious tidal volumes or pressures) is well supported, our understanding of the impact of spontaneous patient efforts (including ventilator asynchronies), more specifically categorized as patient self-inflicted lung injury (P-SILI), on patient outcomes continues to evolve ( Yoshida et al, 2013 ; Yoshida et al, 2020 ; Carteaux et al, 2021 ). As such, ventilator asynchronies like reverse triggering may represent a modifiable risk factor for poor outcomes ( de Haro et al, 2019a ; Marini et al, 2020 ).…”