Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort

Ewan C Goligher, Annemijn H Jonkman, Jose Dianti, Katerina Vaporidi, Jeremy R Beitler, Bhakti K Patel, Takeshi Yoshida, Samir Jaber, Martin Dres, Tommaso Mauri, Giacomo Bellani, Alexandre Demoule, Laurent Brochard, Leo Heunks, Ewan C Goligher, Annemijn H Jonkman, Jose Dianti, Katerina Vaporidi, Jeremy R Beitler, Bhakti K Patel, Takeshi Yoshida, Samir Jaber, Martin Dres, Tommaso Mauri, Giacomo Bellani, Alexandre Demoule, Laurent Brochard, Leo Heunks

Abstract

Mechanical ventilation may have adverse effects on both the lung and the diaphragm. Injury to the lung is mediated by excessive mechanical stress and strain, whereas the diaphragm develops atrophy as a consequence of low respiratory effort and injury in case of excessive effort. The lung and diaphragm-protective mechanical ventilation approach aims to protect both organs simultaneously whenever possible. This review summarizes practical strategies for achieving lung and diaphragm-protective targets at the bedside, focusing on inspiratory and expiratory ventilator settings, monitoring of inspiratory effort or respiratory drive, management of dyssynchrony, and sedation considerations. A number of potential future adjunctive strategies including extracorporeal CO2 removal, partial neuromuscular blockade, and neuromuscular stimulation are also discussed. While clinical trials to confirm the benefit of these approaches are awaited, clinicians should become familiar with assessing and managing patients' respiratory effort, based on existing physiological principles. To protect the lung and the diaphragm, ventilation and sedation might be applied to avoid excessively weak or very strong respiratory efforts and patient-ventilator dysynchrony.

Keywords: Diaphragm weakness; Lung injury; Mechanical ventilation’; Respiratory effort.

Conflict of interest statement

EG is supported by an Early Career Investigator award from the Canadian Institutes of Health Research (AR7-162822). He has received research support in the form of equipment from Getinge and Timpel and personal fees from Getinge. SJ reports receiving consulting fees from Drager, Medtronic, Baxter, Fresenius Medical and Fisher & Paykel. TM received personal fees from Fisher and Paykel, Drager, Mindray, Braun outside of the submitted work. LB’s laboratory reports grants from Medtronic Covidien, grants and non-financial support from Fisher Paykel, non-financial support from Air Liquide, non-financial support from Sentec, non-financial support from Philips, a patent with General Electric, outside the submitted work. LH received research grants from Liberate Medical and Orion Pharma, and travel and speakers fee from Getinge and Orion Pharma.

Figures

Fig. 1
Fig. 1
Principles of lung and diaphragm-protective ventilation. ΔP: change in airway pressure during inspiration; PEEP: positive end-expiratory pressure; P-SILI: patient self-inflicted lung injury; VILI: ventilator-induced lung injury; VT: tidal volume
Fig. 2
Fig. 2
Map of interventions to achieve lung and diaphragm-protective mechanical ventilation. ECCO2R: extracorporeal carbon dioxide removal
Fig. 3
Fig. 3
Clinical-physiological pathway for achieving lung and diaphragm-protective ventilation targets. It should be stressed that at each step clinical evaluation of the patient, including signs of high breathing effort, agitation, and over-sedation is of major importance and should be interpreted together with clinical-physiological measurements as outlined in this pathway. ΔP: change in airway pressure during inspiration; P0.1: decrease in airway pressure during the first 100 ms of inspiratory effort against an occluded airway; PaCO2: arterial carbon dioxide tension; PEEP: positive end-expiratory pressure; Pes: esophageal pressure; PL: transpulmonary pressure; Pocc: airway pressure deflection during a whole breath occlusion; RR: respiratory rate; VT: tidal volume

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