Ventilatory Variables and Mechanical Power in Patients with Acute Respiratory Distress Syndrome

Individualized Multimodal Physiologic Approach to Mechanical Ventilation in Patients With Obesity and Severe Acute Respiratory Distress Syndrome Reduced Venovenous Extracorporeal Membrane Oxygenation Utilization

“…Furthermore, definitive data are still missing on the use of an ultraprotective lung ventilation strategy during VV ECMO, compared with standard ARDSnet tidal volume calculations. However, recently, Del Sorbo et al ( 24 ) demonstrated that there was a linear relationship between tidal volume and plasma biomarkers of ventilator-induced lung injury, whereas Costa et al ( 37 ) found that among ventilator variables, only driving pressure and respiratory rate had significant associations with mortality.…”

“…Despite LRT evaluation and attempt at respiratory optimization, three patients still received VV ECMO. It is important to remark that we do not believe that an individualized approach is an alternative to VV ECMO, since there are clearly states of lung disease that are not amenable to further ventilator optimization and that will only benefit from lung rest ( 23 , 37 , 38 ). However, we believe that this retrospective study indicates that among patients with ARDS who also have obesity, lung recruitment and mechanics can often be further optimized with methods employed by the LRT.…”

Protecting the Injured Right Ventricle in COVID-19 Acute Respiratory Distress Syndrome: Can Clinicians Personalize Interventions and Reduce Mortality?

“…In the context of severe acute respiratory failure, the 'injured' RV is likely to benefit from correction of hypoxemia/hypercapnia/acidemia provided by veno-venous ECMO (VV ECMO) when conventional lung-and RV-protective ventilation (low stress/strain, low driving pressure, low mechanical power) measures fail. 1,25 The reduction in arterial carbon dioxide and improvement in arterial oxygenation has been shown to be associated with a reduction in the mean pulmonary artery pressures within just 15 minutes of commencing VV ECMO support. 26 However, the presence of RV injury is not often factored into the processes of either the selection or timing of the commencement of ECMO support.…”

Intracycle Power and Ventilation Mode as Potential Contributors to Ventilator-Induced Lung Injury

“…One might reasonably question the relative places of the flow-determined maximal intracycle power above pressure threshold (M) and the 'above elastic pressure threshold' energy (A) within the hierarchy of damaging mechanical influences; this ranking awaits further biological evidence. For the individual tidal cycle, transpulmonary plateau pressure and driving pressures are perhaps pre-eminent variables that influence VILI risk and clinical outcomes (4,12,14,15).…”

“…Along this same line, although the externally measured intracycle power levels might seem of small magnitude when related to the whole lung, certain units within the 'baby lung' are likely to bear the brunt of that applied power, concentrating its effect. It goes without saying that the frequency with which the threshold pressure is violated would be critical to overt VILI expression, whatever the intracycle contributors may be that breach it (2,4,14,17).…”