What are the recommendations for managing plateau pressures and driving pressures to prevent ventilator-induced lung injury (VILI)?

From the Guidelines

To prevent ventilator-induced lung injury (VILI), plateau pressures should be maintained below 30 cmH2O and driving pressures (the difference between plateau pressure and PEEP) should be kept below 15 cmH2O. These targets are considered lung-protective ventilation strategies that minimize the risk of barotrauma and volutrauma. When implementing these recommendations, clinicians should use volume-controlled ventilation with tidal volumes of 4-8 mL/kg of predicted body weight, adjust PEEP appropriately (typically 5-15 cmH2O based on oxygenation requirements and lung compliance), and monitor plateau pressures regularly. If plateau pressures exceed 30 cmH2O despite low tidal volumes, consider further reducing tidal volumes, increasing respiratory rate to maintain minute ventilation, optimizing patient-ventilator synchrony, or using neuromuscular blockade in severe cases. These pressure limitations help prevent overdistension of alveoli and cyclic opening and closing of lung units, which are key mechanisms of VILI. Higher driving pressures are independently associated with increased mortality in ARDS patients, as they reflect the strain placed on the lungs during each breath, as suggested by 1.

Some key points to consider when managing plateau pressures and driving pressures include:

• Using volume-controlled ventilation with tidal volumes of 4-8 mL/kg of predicted body weight 1
• Adjusting PEEP appropriately based on oxygenation requirements and lung compliance 1
• Monitoring plateau pressures regularly and adjusting ventilator settings as needed 1
• Considering further reduction of tidal volumes, increasing respiratory rate, optimizing patient-ventilator synchrony, or using neuromuscular blockade if plateau pressures exceed 30 cmH2O despite low tidal volumes 1
• Recognizing that higher driving pressures are associated with increased mortality in ARDS patients, as they reflect the strain placed on the lungs during each breath 1.

Regular assessment of respiratory mechanics and adjustment of ventilator settings based on individual patient characteristics is essential for effective implementation of these recommendations, as emphasized by 1. By following these guidelines, clinicians can help minimize the risk of VILI and improve outcomes for patients with ARDS.

From the Research

Plateau Pressures and Driving Pressures

Plateau pressures and driving pressures are crucial parameters in mechanical ventilation that can impact the development of ventilator-induced lung injury (VILI).

• Plateau pressure is the pressure applied to the lungs at the end of inhalation, when airflow is stopped, and is an indicator of the stress applied to the lung tissue.
• Driving pressure, on the other hand, is the difference between the plateau pressure and the positive end-expiratory pressure (PEEP), and it reflects the distending pressure of the lung.

Managing Plateau Pressures and Driving Pressures

To prevent VILI, it is essential to manage plateau pressures and driving pressures effectively.

• The study by 2 suggests that low driving pressure is a computational biomarker associated with better experimental VILI outcomes and supports the use of driving pressure to guide ventilator adjustments to prevent VILI.
• Another study by 3 highlights the importance of avoiding high plateau pressure as a mechanism of harm that can lead to VILI.
• The review by 4 emphasizes the need to set optimal PEEP levels and reduce tidal volume to prevent VILI.
• Additionally, the study by 5 notes that VILI prevention strategies must balance the risk of lung injury with untoward side effects from the preventive effort and may be most effective when targeted to subsets of patients at increased risk.
• The review by 6 provides a comprehensive assessment of the pathogenesis of VILI and its determinants, and discusses the best preventive approach in patients with or at risk for ARDS.

Recommendations

Based on the available evidence, the following recommendations can be made:

• Use low driving pressure as a guide for ventilator adjustments to prevent VILI 2.
• Avoid high plateau pressure to minimize the risk of VILI 3.
• Set optimal PEEP levels and reduce tidal volume to prevent VILI 4.
• Balance the risk of lung injury with untoward side effects from the preventive effort and target prevention strategies to subsets of patients at increased risk 5.
• Implement lung-protective mechanical ventilation founded on the basic principles of VILI pathogenesis to improve hospital and long-term mortality 6.