Skip to Main Content

++

KEY POINTS

++

  • Ventilator-induced lung injury (VILI) may occur with both lung volumes that lead to overdistention of lung units (volutrauma) or with low distending pressures that allow the lung to be recruited and derecruited (atelectrauma).

  • VILI may cause injury in previously healthy regions of lung, and may also lead to multiorgan dysfunction.

  • To reduce the risk of VILI, limitation of end-inspiratory stretch using low tidal volumes ∼6 mL/kg and limiting plateau pressure (Pplat) <30 cm H2O should be used in treating most patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). Higher Pplat may be used in patients with poorly compliant chest walls.

  • The appropriate level of positive end-expiratory pressure remains to be determined, but levels of PEEP that minimize atelectasis may be beneficial.

  • Permissive hypoventilation (hypercapnia) may be a necessary component of a lung-protective ventilator strategy.

  • The penetrance of lung-protective ventilation strategies into clinical practice is improving.

++

There is consistent and convincing evidence that mechanical ventilation, particularly in the setting of lung injury, can contribute to functional and structural alterations in the lung. The experimental evidence has also led to the notion that mechanical ventilation not only perpetuates lung injury, but also contributes to both the morbidity and mortality of the acute respiratory distress syndrome (ARDS). Concern surrounding ventilator-induced lung injury (VILI) culminated in a consensus conference in 1993 that recommended (based solely on studies in animal models of ARDS) tidal volumes be limited to the range of 5 to 7 mL/kg and plateau pressures less than 35 cm H2O.1 It would be 8 years until the recommendations of the consensus group were affirmed by a randomized controlled trial demonstrating that a lung-protective strategy led to a decrease in mortality in patients with acute lung injury.2 After initial hesitations about the incorporation of these concepts into widespread clinical practice,3 lower tidal volumes and higher levels of positive end-expiratory pressure (PEEP) are being used widely to minimize VILI.4,5

++

The objectives of this chapter are to review current concepts of VILI and provide the rationale for lung-protective ventilation strategies. Since most studies evaluating VILI have focused on ARDS, the relevant features of ARDS as it pertains to VILI will be reviewed first. Then, the concept of lung-protective ventilation strategies will be discussed, and pertinent studies evaluating these newer strategies in patients with ARDS will be presented. Recommendations based on current clinical evidence, and when this is lacking best experimental evidence, will also be presented (Table 51-1).

++
Table Graphic Jump Location
TABLE 51-1

Goals of Mechanical Ventilation Modified to Reduce the Risk of Ventilator-Induced Lung Injury

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.