From the Guidelines
Ventilator-induced lung injury (VILI) treatment should focus on implementing lung-protective ventilation strategies, including the use of low tidal volumes, appropriate positive end-expiratory pressure (PEEP), and prone positioning, as these approaches have been shown to reduce morbidity, mortality, and improve quality of life in patients with acute respiratory distress syndrome (ARDS) 1.
Key Components of VILI Treatment
- Low tidal volumes of 4-6 mL/kg of predicted body weight to prevent alveolar overdistension
- Maintaining plateau pressures below 30 cmH2O to reduce the risk of barotrauma
- Applying appropriate PEEP typically between 5-15 cmH2O based on the patient's condition to prevent atelectrauma
- Permissive hypercapnia may be necessary, allowing PaCO2 to rise while maintaining pH above 7.25 to minimize ventilator-induced lung injury
- Prone positioning for 16+ hours daily is beneficial for patients with moderate-to-severe ARDS, as it improves oxygenation and reduces the risk of VILI 1
- Neuromuscular blockade with agents like cisatracurium (37.5 mg/hr continuous infusion) may be needed for the first 48 hours in severe cases to prevent ventilator dyssynchrony
- Fluid management should be conservative to reduce pulmonary edema and minimize the risk of VILI
Rationale and Evidence
The use of lung-protective ventilation strategies in patients with ARDS has been shown to reduce morbidity and mortality, and improve quality of life 1. The application of low tidal volumes and appropriate PEEP can prevent alveolar overdistension and atelectrauma, reducing the risk of VILI. Prone positioning has been shown to improve oxygenation and reduce the risk of VILI in patients with moderate-to-severe ARDS 1. The use of neuromuscular blockade and conservative fluid management can also help to minimize the risk of VILI.
Recent Guidelines and Recommendations
Recent guidelines and recommendations support the use of lung-protective ventilation strategies in patients with ARDS, including the use of low tidal volumes, appropriate PEEP, and prone positioning 1. These guidelines also recommend the use of neuromuscular blockade and conservative fluid management in severe cases.
Ongoing Research and Future Directions
Ongoing research is focused on identifying new strategies to prevent and treat VILI, including the use of extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal (ECCO2R) 1. However, these strategies are still in the early stages of development, and more research is needed to determine their effectiveness in reducing morbidity, mortality, and improving quality of life in patients with ARDS.
From the Research
Treatment of Ventilator-Induced Lung Injury (VILI)
To treat VILI, several strategies can be employed:
- Minimize inspiratory and expiratory stress, dynamic and static strain, energy, mechanical power, and intensity 2
- Use prone positioning in patients with moderate to severe ARDS to reduce lung damage and improve survival 2
- Consider extracorporeal support in selected cases 2
- Implement a multifaceted protocolized ventilation strategy that includes low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure 3
- Use noninvasive ventilation, which can prevent the complications of intubation, but be aware of its potential to cause harm, especially in patients with de novo respiratory failure 4
Ventilation Strategies
The following ventilation strategies can help prevent VILI:
- Low tidal volume ventilation, with target tidal volumes of 6 mL/kg of predicted body weight 3
- High positive end-expiratory pressure, with mean positive end-expiratory pressures of 14.6 cm H2O 3
- Recruitment maneuvers to open collapsed lung tissue 3
- Lung-protective mechanical ventilation, which includes the use of low tidal volumes, positive end-expiratory pressure, and recruitment maneuvers 5
Prevention of VILI
Prevention of VILI is crucial to attenuate multiorgan failure and improve survival in at-risk patients: