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

Abstract

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.

Lung ultrasound score-based assessment of postoperative atelectasis in obese patients according to inspired oxygen concentration: A prospective, randomized-controlled study

“…This is important because ventilation for only a few minutes with an inhaled oxygen concentration of 1.0 markedly increases atelectasis after induction compared with ventilation with lower oxygen concentration. [11,26] In addition, during normal respiration, the diaphragm contracts, pushing the abdominal contents down and forward, and contraction of the external intercostal muscles pulls the ribs upward and forward. [27] However, obese patients are affected in this normal mechanism because they have excess body fat that is distributed in the chest and takes up the abdomen and restricts the action of the respiratory muscles.…”

Intraoperative Ventilator Management of the Critically Ill Patient

“…For simplicity of intraoperative management, there is an understandable desire to standardize mechanical ventilation for all patients undergoing surgery, yet there is evidence that this standardized approach may not be optimal or may even be detrimental depending on patient characteristics and surgical conditions. 4 Furthermore, selective targeting of a fixed TV, airway pressure, or gas exchange value may conflict with other protective ventilation goals. 5 Importantly, the stress and strain applied to the lung are not directly measured with standard LPV settings but are inferred from respiratory mechanics.…”