Ventilatory support and mechanical properties of the fibrotic lung acting as a “squishy ball”

Marchioni, Alessandro; Tonelli, Roberto; Rossi, Giulio; Spagnolo, Paolo; Luppi, Fabrizio; Cerri, Stefania; Cocconcelli, Elisabetta; Pellegrino, Maria Rosaria; Fantini, Riccardo; Tabbì, Luca; Castaniere, Ivana; Ball, Lorenzo; Malbrain, Manu L. N. G.; Pelosi, Paolo; Clini, Enrico

Protective ventilation is the cornerstone of treatment of patients with the acute respiratory distress syndrome (ARDS); however, no studies have yet established the best ventilatory strategy to adopt when patients with acute exacerbation of interstitial lung disease (AE-ILD) are admitted to the intensive care unit. Due to the severe impairment of the respiratory mechanics, the fibrotic lung is at high risk of developing ventilator-induced lung injury, regardless of the lung fibrosis etiology. The purpose of this review is to analyze the effects of mechanical ventilation in AE-ILD and to increase the knowledge on the characteristics of fibrotic lung during artificial ventilation, introducing the concept of “squishy ball lung”. The role of positive end-expiratory pressure is discussed, proposing a “lung resting strategy” as opposed to the “open lung approach”. The review also discusses the practical management of AE-ILD patients discussing illustrative clinical cases.