RESPIRATORY SYSTEM: Edited by Ewan C. Goligher and Eddy FanPatient self-inflicted lung injury and positive end-expiratory pressure for safe spontaneous breathingYoshida, Takeshia; Grieco, Domenico L.b,c; Brochard, Laurentd; Fujino, YujiaAuthor Information aDepartment of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan bDepartment of Emergency and Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS cDepartment of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy dInterdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada Correspondence to Takeshi Yoshida, MD, Ph.D., Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan. Tel: +81 6 6879 5820; fax: +81 6 6879 5823; e-mail: [email protected] Current Opinion in Critical Care: February 2020 - Volume 26 - Issue 1 - p 59-65 doi: 10.1097/MCC.0000000000000691 Buy Metrics Abstract Purpose of review The potential risks of spontaneous effort and their prevention during mechanical ventilation is an important concept for clinicians and patients. The effort-dependent lung injury has been termed ‘patient self-inflicted lung injury (P-SILI)’ in 2017. As one of the potential strategies to render spontaneous effort less injurious in severe acute respiratory distress syndrome (ARDS), the role of positive end-expiratory pressure (PEEP) is now discussed. Recent findings Experimental and clinical data indicate that vigorous spontaneous effort may worsen lung injury, whereas, at the same time, the intensity of spontaneous effort seems difficult to control when lung injury is severe. Experimental studies found that higher PEEP strategy can be effective to reduce lung injury from spontaneous effort while maintaining some muscle activity. The recent clinical trial to reevaluate systemic early neuromuscular blockade in moderate–severe ARDS (i.e., reevaluation of systemic early neuromuscular blockade (ROSE) trial) support that a higher PEEP strategy can facilitate ‘safe’ spontaneous breathing under the light sedation targets (i.e., no increase in barotrauma nor 90 days mortality versus early muscle paralysis). Summary To prevent P-SILI in ARDS, it seems feasible to facilitate ‘safe’ spontaneous breathing in patients using a higher PEEP strategy in severe ARDS. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.