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

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 diaphra...

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Bibliographic Details
Published in:Intensive care medicine 2020-12, Vol.46 (12), p.2314-2326
Main Authors: Goligher, Ewan C., Jonkman, Annemijn H., Dianti, Jose, Vaporidi, Katerina, Beitler, Jeremy R., Patel, Bhakti K., Yoshida, Takeshi, Jaber, Samir, Dres, Martin, Mauri, Tommaso, Bellani, Giacomo, Demoule, Alexandre, Brochard, Laurent, Heunks, Leo
Format: Article
Language:English
Subjects:
Anesthesia
Anesthesiology
Atrophy
Carbon dioxide
Clinical trials
Critical Care Medicine
Diaphragm
Diaphragm (Anatomy)
Emergency Medicine
Intensive
Intensive care
Life Sciences
Lungs
Mechanical ventilation
Medical colleges
Medical research
Medicine
Medicine & Public Health
Medicine, Experimental
Narrative Review
Organs
Pain Medicine
Pediatrics
Physiological aspects
Pneumology/Respiratory System
Respiration
Ventilation
Ventilators
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Summary: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 CO 2 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.
ISSN:0342-4642
1432-1238
DOI:10.1007/s00134-020-06288-9