Personalized mechanical ventilation in acute respiratory distress syndrome

Abstract

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.

Effects of different positive end-expiratory pressure titration strategies during prone positioning in patients with acute respiratory distress syndrome: a prospective interventional study

“…To minimize a potential interaction between different PEEP titration strategies and positioning, a 30-min equilibration period between the measurements was permitted [ 51 ]. Similarly, a recruitment maneuver was performed to standardize the history of lung volume [ 52 ] between each measurement, although frequent recruitment maneuvers are not systematically recommended [ 5 ]. Individual recruitability was not assessed before the study to account for differences in lung morphology.…”

“…However, during protective mechanical ventilation, the optimal PEEP titration strategy remains controversial when taking into account the differences in lung recruitability of the individual patient [ 4 ]. Several strategies have been proposed to set PEEP [ 5 ]: (A) the use of a minimal PEEP level to achieve adequate oxygenation [ 6 ] according to the lower PEEP/fraction of inspired oxygen (FiO 2 ) table, which was recommended by the ARDS Network [ 7 ]; (B) evaluation of the lowest static elastance of the respiratory system ( E stat,RS ) [ 8 ] aiming to achieve the lowest driving pressure ( P driv ), thus determining a compromise between recruitment and overinflation [ 9 , 10 ]; and (C) targeting a positive Ptp exp to account for variability in lung and chest wall mechanics and optimize alveolar recruitment [ 11 ]. The pleural pressure is increased in dependent lung regions leading to alveolar collapse [ 12 ], therefore the application of a matched PEEP should counteract the pleural pressure and thus promote the balance between recruitment and overdistension [ 13 ].…”

Laboratory Biomarkers for Diagnosis and Prognosis in COVID-19

“…Severe and critical illness accounts for up to 14% and 5% of cases, respectively, with the ARDS occurring in 10-20% of patients; multiorgan failure and death may supervene ( 13 , 14 ). Various phenotypes have been identified by computed tomography (CT) ( 15 , 16 ), including phenotype L or 1, which is characterized by low compliance, altered ventilation and perfusion, and shunting with focal hypo/hyper-perfused ground-glass opacities; and phenotype H or 2, which is identified by an inhomogeneous distribution of atelectasis with a patchy ARDS-like pattern ( 17 , 18 ). Progressive evolution of COVID-19 ( 19 ) may lead to phenotype F, caused by mechanical stretch of lung epithelial cells and pathological fibro-proliferation and remodeling of the extracellular matrix, with increased expression of pro-fibrotic markers, as is mainly typical of severe forms of lung disease ( 20 ).…”

Current Practice of Fluid Maintenance and Replacement Therapy in Mechanically Ventilated Critically Ill Children: A European Survey

“…Trials for fluid therapy in children have been proposed for many years but still not accomplished ( 30 ). The general opinion seems to be that both hemodynamic and respiratory therapy needs to be personalized implying that a one-size-fits all strategy will not be realistic ( 20 , 31 ).…”