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Bedside respiratory physiology to detect risk of lung injury in acute respiratory distress syndrome

Beitler, Jeremy R.

Current Opinion in Critical Care: February 2019 - Volume 25 - Issue 1 - p 3–11
doi: 10.1097/MCC.0000000000000579
RESPIRATORY SYSTEM: Edited by Laurent J. Brochard and Tài Pham
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Purpose of review The most effective strategies for treating the patient with acute respiratory distress syndrome center on minimizing ventilation-induced lung injury (VILI). Yet, current standard-of-care does little to modify mechanical ventilation to patient-specific risk. This review focuses on evaluation of bedside respiratory mechanics, which when interpreted in patient-specific context, affords opportunity to individualize lung-protective ventilation in patients with acute respiratory distress syndrome.

Recent findings Four biophysical mechanisms of VILI are widely accepted: volutrauma, barotrauma, atelectrauma, and stress concentration. Resulting biotrauma, that is, local and systemic inflammation and endothelial activation, may be thought of as the final common pathway that propagates VILI-mediated multiorgan failure. Conventional, widely utilized techniques to assess VILI risk rely on airway pressure, flow, and volume changes, and remain essential tools for determining overdistension of aerated lung regions, particularly when interpreted cognizant of their limitations. Emerging bedside tools identify regional differences in mechanics, but further study is required to identify how they might best be incorporated into clinical practice.

Summary Quantifying patient-specific risk of VILI requires understanding each patient's pulmonary mechanics in context of biological predisposition. Tailoring support at bedside according to these factors affords the greatest opportunity to date for mitigating VILI and alleviating associated morbidity.

Division of Pulmonary, Allergy, and Critical Care Medicine, Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons, New York, New York, USA

Correspondence to Jeremy R. Beitler, MD, MPH, Division of Pulmonary, Allergy, and Critical Care Medicine, Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH 8 East-101, New York, NY 10032, USA. Tel: +1 212 342 2845; e-mail: jrb2266@cumc.columbia.edu

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