Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effo
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NARRATIVE REVIEW
Clinical strategies for implementing lung and diaphragm‑protective ventilation: avoiding insufficient and excessive effort Ewan C. Goligher1,2,3, Annemijn H. Jonkman4,5, Jose Dianti1,2, Katerina Vaporidi6, Jeremy R. Beitler7, Bhakti K. Patel8, Takeshi Yoshida9, Samir Jaber10, Martin Dres11,12, Tommaso Mauri13,14, Giacomo Bellani15, Alexandre Demoule11,12, Laurent Brochard1,5 and Leo Heunks4* © 2020 The Author(s)
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 C O2 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: Mechanical ventilation’, Lung injury, Diaphragm weakness, Respiratory effort Introduction Lung and diaphragm-protective mechanical ventilation is a novel approach that aims to limit side effects of mechanical ventilation in critically ill patients. This approach integrates the principles of lung-protective ventilation with the new concept of diaphragm-protective ventilation in an effort to simultaneously protect both organs. The approach centers on optimizing patient respiratory effort to avoid lung and diaphragm injury while maintaining acceptable respiratory homeostasis. *Correspondence: [email protected] 4 Department of Intensive Care, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands Full author information is available at the end of the article
Ultimately, the goal of the approach is to reduce the duration of mechanical ventilation, enhance survival, accelerate recovery, and prevent long-term disability in patients with acute respiratory failure.
Principles and rationale Principles of lung‑protective ventilation
Lung-protective ventilation can best be understood in terms of limiting global and regional mechanical stress (pressure applied to the lung) and strain (deformation from resting shape) (Fig. 1). Lung injury may occur from overdistension (volutrauma/barotrauma), repetitive tidal
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