Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort

Goligher, Ewan C.; Jonkman, Annemijn H.; Dianti, Jose; Vaporidi, Katerina; Beitler, Jeremy R.; Patel, Bhakti K.; Yoshida, Takeshi; Jaber, Samir; Dres, Martin; Mauri, Tommaso; Bellani, Giacomo; Demoule, Alexandre; Brochard, Laurent; Heunks, Leo

Mechanical ventilation may have adverse effects on both the lung and the diaphragm. Injury to the lung is mediated by excessive mechanical stress and strain, whereas the diaphragm develops atrophy as a consequence of low respiratory effort and injury in case of excessive effort. The lung and diaphragm-protective mechanical ventilation approach aims to protect both organs simultaneously whenever possible. This review summarizes practical strategies for achieving lung and diaphragm-protective targets at the bedside, focusing on inspiratory and expiratory ventilator settings, monitoring of inspiratory effort or respiratory drive, management of dyssynchrony, and sedation considerations. A number of potential future adjunctive strategies including extracorporeal CO(2) removal, partial neuromuscular blockade, and neuromuscular stimulation are also discussed. While clinical trials to confirm the benefit of these approaches are awaited, clinicians should become familiar with assessing and managing patients’ respiratory effort, based on existing physiological principles. To protect the lung and the diaphragm, ventilation and sedation might be applied to avoid excessively weak or very strong respiratory efforts and patient-ventilator dysynchrony.