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Diaphragm-protective mechanical ventilation

Schepens, Toma; Dres, Martinb,c; Heunks, Leod; Goligher, Ewan C.e,f,g

Current Opinion in Critical Care: February 2019 - Volume 25 - Issue 1 - p 77–85
doi: 10.1097/MCC.0000000000000578
RESPIRATORY SYSTEM: Edited by Laurent J. Brochard and Tài Pham
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Purpose of review Diaphragm dysfunction is common in mechanically ventilated patients and predisposes them to prolonged ventilator dependence and poor clinical outcomes. Mechanical ventilation is a major cause of diaphragm dysfunction in these patients, raising the possibility that diaphragm dysfunction might be prevented if mechanical ventilation can be optimized to avoid diaphragm injury – a concept referred to as diaphragm-protective ventilation. This review surveys the evidence supporting the concept of diaphragm-protective ventilation and introduces potential routes and challenges to pursuing this strategy.

Recent findings Mechanical ventilation can cause diaphragm injury (myotrauma) by a variety of mechanisms. An understanding of these various mechanisms raises the possibility of a new approach to ventilatory management, a diaphragm-protective ventilation strategy. Deranged inspiratory effort is the main mediator of diaphragmatic myotrauma; titrating ventilation to maintain an optimal level of inspiratory effort may help to limit diaphragm dysfunction and accelerate liberation of mechanical ventilation.

Summary Mechanical ventilation can cause diaphragm injury and weakness. A novel diaphragm-protective ventilation strategy, avoiding the harmful effects of both excessive and insufficient inspiratory effort, has the potential to substantially improve outcomes for patients.

aDepartment of Critical Care Medicine, Antwerp University Hospital, University of Antwerp, Edegem, Belgium

bDépartement ‘R3S’, Service de Pneumologie, Médecine Intensive et Réanimation, AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix

cUMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM, Sorbonne Université, Paris, France

dDepartment of Intensive Care, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands

eInterdepartmental Division of Critical Care Medicine, University of Toronto

fDivision of Respirology, Department of Medicine, University Health Network

gToronto General Hospital Research Institute, Toronto, Ontario, Canada

Correspondence to Ewan C. Goligher, MD, PhD, Critical Care Medicine, Toronto General Hospital, 585 University Ave., Peter Munk Building, 11th Floor, Room 192, Toronto, ON M5G 2N2, Canada. Tel: +1 416 340 4800 ext 6810; e-mail: ewan.goligher@utoronto.ca

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