RESPIRATORY SYSTEM: Edited by Ewan C. Goligher and Eddy FanDiaphragm protection: what should we target?Schepens, Toma; Dianti, Joseb,cAuthor Information aDepartment of Critical Care Medicine, Antwerp University Hospital, Antwerp, Belgium bInterdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada cDepartment of Medicine, Adult Intensive Care Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina Correspondence to Tom Schepens, Department of Critical Care Medicine, Antwerp University Hospital, Wilrijkstraat 10, 2650 Edegem, Belgium. Tel: +32 3 821 36 35; e-mail: [email protected] Current Opinion in Critical Care: February 2020 - Volume 26 - Issue 1 - p 35-40 doi: 10.1097/MCC.0000000000000683 Buy Metrics Abstract Purpose of review Diaphragm weakness can impact survival and increases comorbidities in ventilated patients. Mechanical ventilation is linked to diaphragm dysfunction through several mechanisms of injury, referred to as myotrauma. By monitoring diaphragm activity and titrating ventilator settings, the critical care clinician can have a direct impact on diaphragm injury. Recent findings Both the absence of diaphragm activity and excessive inspiratory effort can result in diaphragm muscle weakness, and recent evidence demonstrates that a moderate level of diaphragm activity during mechanical ventilation improves ICU outcome. This supports the hypothesis that by avoiding ventilator overassistance and underassistance, the clinician can implement a diaphragm-protective ventilation strategy. Furthermore, eccentric diaphragm contractions and end-expiratory shortening could impact diaphragm strength as well. This review describes these potential targets for diaphragm protective ventilation. Summary A ventilator strategy that results in appropriate levels of diaphragm activity has the potential to be diaphragm-protective and improve clinical outcome. Monitoring respiratory effort during mechanical ventilation is becoming increasingly important. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.