What is the treatment for Ventilator-Induced Lung Injury (VILI) after intubation?

From the Guidelines

To treat ventilator-induced lung injury (VILI) post intubation, implement a lung-protective ventilation strategy immediately, using low tidal volumes of 4-6 mL/kg of predicted body weight and maintaining plateau pressures below 30 cmH2O, as recommended by the American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline 1. This approach is crucial in reducing mechanical stress on lung tissue and preventing repetitive alveolar collapse and reopening, which can exacerbate lung injury. Key components of this strategy include:

• Using low tidal volumes to minimize lung stretch and injury
• Maintaining appropriate positive end-expiratory pressure (PEEP) to prevent alveolar collapse and optimize oxygenation
• Considering prone positioning for 12-16 hours daily in cases of moderate-to-severe ARDS to improve ventilation-perfusion matching, as supported by the clinical practice guideline 1
• Implementing neuromuscular blockade with agents like cisatracurium in the first 48 hours for severe cases to reduce ventilator dyssynchrony
• Maintaining a conservative fluid management strategy to minimize pulmonary edema
• Adjusting ventilator settings based on frequent blood gas analyses and continuous monitoring of oxygen saturation to ensure optimal ventilation and oxygenation. These interventions are critical in reducing morbidity, mortality, and improving quality of life for patients with VILI post intubation, and should be guided by the most recent and highest quality evidence, such as the 2017 clinical practice guideline 1.

From the Research

Treatment of VILI Post Intubation

To treat Ventilator-Induced Lung Injury (VILI) post intubation, several strategies can be employed:

• Use of low tidal volume ventilation to minimize volutrauma and barotrauma 2
• Application of positive end-expiratory pressure (PEEP) to prevent atelectrauma, but with caution to avoid increased pulmonary vascular resistance and hemodynamic impairment 3
• Recruitment maneuvers to improve ventilation/perfusion and prevent alveolar collapse 3, 4
• Use of noninvasive ventilation to prevent complications of intubation, but with awareness of its potential to cause harm in patients with de novo respiratory failure 5
• Targeted use of PEEP according to driving pressure to obtain optimum respiratory and pulmonary system compliance 3

Protective Ventilation Strategies

Protective ventilation strategies that can be used to prevent VILI include:

• Low tidal volume ventilation with moderate levels of PEEP to prevent tidal alveolar collapse and overdistension 4
• Pressure-controlled ventilation to regulate peak inspiratory pressures 4
• High frequency oscillatory ventilation and airway pressure release ventilation, although definitive trials are still needed to identify consistently improved patient outcomes 4
• Extracorporeal support to facilitate protective ventilation and mitigate VALI 6

Prevention of VILI

Prevention of VILI is crucial, and can be achieved by:

• Detecting at-risk patients and implementing protective ventilation early 6
• Identifying injurious ventilation and potential biological markers of VALI 6
• Using lung protective ventilation strategies consistently, and promoting timely discontinuation of mechanical ventilation 4