Patient Self-Inflicted Lung Injury-A Narrative Review of Pathophysiology, Early Recognition, and Management Options

Peter Sklienka, Michal Frelich, Filip Burša, Peter Sklienka, Michal Frelich, Filip Burša

Abstract

Patient self-inflicted lung injury (P-SILI) is a life-threatening condition arising from excessive respiratory effort and work of breathing in patients with lung injury. The pathophysiology of P-SILI involves factors related to the underlying lung pathology and vigorous respiratory effort. P-SILI might develop both during spontaneous breathing and mechanical ventilation with preserved spontaneous respiratory activity. In spontaneously breathing patients, clinical signs of increased work of breathing and scales developed for early detection of potentially harmful effort might help clinicians prevent unnecessary intubation, while, on the contrary, identifying patients who would benefit from early intubation. In mechanically ventilated patients, several simple non-invasive methods for assessing the inspiratory effort exerted by the respiratory muscles were correlated with respiratory muscle pressure. In patients with signs of injurious respiratory effort, therapy aimed to minimize this problem has been demonstrated to prevent aggravation of lung injury and, therefore, improve the outcome of such patients. In this narrative review, we accumulated the current information on pathophysiology and early detection of vigorous respiratory effort. In addition, we proposed a simple algorithm for prevention and treatment of P-SILI that is easily applicable in clinical practice.

Keywords: extracorporeal membranous oxygenation; patient self-inflicted lung injury; respiratory effort; transpulmonary driving pressure; work of breathing.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
The pathophysiology of P-SILI—a “vicious circle” of self-aggravating lung injury; yellow arrow—vagal signalization (according to [5,10,18]).
Figure 2
Figure 2
Noninvasive or minimally invasive bedside tools for detection of potentially injurious respiratory effort. Blue square—methods of indirect detection of vigorous spontaneous effort in patients breathing spontaneously or on noninvasive ventilation. White square—methods applicable both during spontaneous breathing and mechanical ventilation. Green square—methods applicable under mechanical ventilation. Abbreviations: WOB—work of breathing; HFNC—high-flow nasal cannula; NIV—noninvasive ventilation; SpO2—peripheral oxygen saturation; FiO2—fraction of inspired oxygen; RR—respiratory rate; HR—heart rate; GCS—Glasgow Coma Scale; paO2—arterial partial pressure of oxygen; Pes—esophageal pressure; ΔPes—esophageal pressure swings; Pmus—respiratory muscle pressure; PL—transpulmonary pressure; Vt—tidal volume; IBW—ideal body weight; P0.1—airway occlusion pressure at 100 ms; Pocc—expiratory occlusion pressure.
Figure 3
Figure 3
Proposal of an algorithm for P-SILI prevention and treatment. CMV—controlled mechanical ventilation; HFNC—high-flow nasal cannula; NIV—noninvasive ventilation; PNX—pneumothorax; PNM—pneumomediastinum; ECMO—extracorporeal membranous oxygenation.

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