Ten golden rules for individualized mechanical ventilation in acute respiratory distress syndrome

Abstract

Over the last decades, great strides have been made in the management of acute respiratory distress syndrome (ARDS). Mechanical ventilation remains the cornerstone of supportive therapy for ARDS. Lung-protective mechanical ventilation minimizes the risk of ventilator-induced lung injury (VILI) and improves survival. Several parameters are determinants of VILI and require careful setting, such as tidal volume (V T ), plateau pressure (Pplat), driving pressure (DP), positive end-expiratory pressure (PEEP), and respiratory rate. Furthermore, measurement of energy and mechanical power may enable quantification of the relative contribution of its different components (V T , Pplat, ΔP, PEEP, respiratory rate, and airflow) and better individualize mechanical ventilation settings. The use of neuromuscular blocking agents is of interest, mainly in cases of severe ARDS, to improve oxygenation and reduce asynchrony; however, no significant changes in survival have been observed. Rescue respiratory therapies, such as prone positioning, inhaled nitric oxide, and extracorporeal support techniques may also be used in specific situations. Furthermore, respiratory weaning protocols should be discussed. After reviewing all recent clinical trials, we now present 10 golden rules to individualize mechanical ventilation in ARDS management.

Personalized mechanical ventilation in acute respiratory distress syndrome

“…At the bedside, clinicians seek to implement this evidence and adjust this "powerful instrument" by understanding physiologic mechanisms and possible consequences of ventilatory interventions [7]. Key goals are to relieve excessive workload of breathing and improve gas exchange, without impairing hemodynamics or incurring iatrogenic injury from intolerable pressures or inspired oxygen [8]. Notwithstanding, selective targeting of one of these objectives may collide with goals of another [9].…”

Mechanical Power Correlates With Lung Inflammation Assessed by Positron-Emission Tomography in Experimental Acute Lung Injury in Pigs

“…In addition, titrating PEEP according to lung morphology did not improve outcome and even increased mortality if morphology was misclassified, respectively. Thus, as proposed earlier ( Brower et al, 2004 ), fixed PEEP/F I O 2 combinations should still be used for patients with ARDS ( Chiumello et al, 2014 ; Battaglini et al, 2021 ), which justified our selected experimental setting.…”

“…Inhomogeneous lung aeration can further aggravate mechanical stress and lung injury ( Mead et al, 1970 ). Although certain measures to prevent VILI have been established ( Acute Respiratory Distress Syndrome Network Brower et al, 2000 ; Amato et al, 2015 ), e.g., limitation of tidal volume (V T ) or airway plateau and driving pressures, discussion about adequate levels of positive end-expiratory pressure (PEEP) is ongoing, and the interplay among parameters is complex ( Battaglini et al, 2021 ). Irrespectively of specific parameters, mechanical energy is inevitably transferred to the respiratory system in every single MV cycle, resulting in transferred mechanical power (MP) when multiplied with respiratory rate (RR).…”

Personalized medicine using omics approaches in acute respiratory distress syndrome to identify biological phenotypes

“…Increasing effort has been made to elucidate which treatments or supportive interventions can be used [ 6 , 7 ]. Existing treatments for ARDS are mainly supportive [ 8 ].…”