Ten golden rules for individualized mechanical ventilation in acute respiratory distress syndrome

Denise Battaglini; Marco Sottano; Lorenzo Ball; Chiara Robba; Patricia R M Rocco; Paolo Pelosi

doi:10.1016/j.jointm.2021.01.003

Ten golden rules for individualized mechanical ventilation in acute respiratory distress syndrome

J Intensive Med. 2021 Feb 5;1(1):42-51. doi: 10.1016/j.jointm.2021.01.003. eCollection 2021 Jul.

Authors

Denise Battaglini^{1

2}, Marco Sottano^{1

3}, Lorenzo Ball^{1

3}, Chiara Robba^{1

3}, Patricia R M Rocco⁴, Paolo Pelosi^{1

3}

Affiliations

¹ Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa 16132, Italy.
² Department of Medicine, University of Barcelona, Barcelona 08007, Spain.
³ Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa 16126, Italy.
⁴ Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil.

Abstract

Considerable progress has been made over the last decades in the management of acute respiratory distress syndrome (ARDS). Mechanical ventilation(MV) remains the cornerstone of supportive therapy for ARDS. Lung-protective MV minimizes the risk of ventilator-induced lung injury (VILI) and improves survival. Several parameters contribute to the risk of VILI and require careful setting including tidal volume (V_T), plateau pressure (P_plat), driving pressure (ΔP), positive end-expiratory pressure (PEEP), and respiratory rate. Measurement of energy and mechanical power allows quantification of the relative contributions of various parameters (V_T, P_plat, ΔP, PEEP, respiratory rate, and airflow) for the individualization of MV settings. The use of neuromuscular blocking agents mainly in cases of severe ARDS can improve oxygenation and reduce asynchrony, although they are not known to confer a survival benefit. Rescue respiratory therapies such as prone positioning, inhaled nitric oxide, and extracorporeal support techniques may be adopted in specific situations. Furthermore, respiratory weaning protocols should also be considered. Based on a review of recent clinical trials, we present 10 golden rules for individualized MV in ARDS management.

Keywords: Acute respiratory distress syndrome (ARDS); Extracorporeal CO2 removal (ECCO2R); Extracorporeal membrane oxygenation (ECMO); Protective mechanical ventilation.

Publication types

Review