Novel approaches to minimize ventilator-induced lung injury

Abstract

Despite over 40 years of research, there is no specific lung-directed therapy for the acute respiratory distress syndrome (ARDS). Although much has evolved in our understanding of its pathogenesis and factors affecting patient outcome, supportive care with mechanical ventilation remains the cornerstone of treatment. Perhaps the most important advance in ARDS research has been the recognition that mechanical ventilation, although necessary to preserve life, can itself aggravate or cause lung damage through a variety of mechanisms collectively referred to as ventilator-induced lung injury (VILI). This improved understanding of ARDS and VILI has been important in designing lung-protective ventilatory strategies aimed at attenuating VILI and improving outcomes. Considerable effort has been made to enhance our mechanistic understanding of VILI and to develop new ventilatory strategies and therapeutic interventions to prevent and ameliorate VILI with the goal of improving outcomes in patients with ARDS. In this review, we will review the pathophysiology of VILI, discuss a number of novel physiological approaches for minimizing VILI, therapies to counteract biotrauma, and highlight a number of experimental studies to support these concepts.

Figure 1

Mechanisms for VILI and potential targets for physiologic and non-physiologic interventions to minimize VILI. Reprinted with permission of the American Thoracic Society. Copyright (C) 2013 American Thoracic Society. Slutsky AS, Tremblay LN: Multiple system organ failure: is mechanical ventilation a contributing factor? Am J Resp Crit Care Med 1998, 157:1721–1725. ECLS, extracorporeal life support; LT, leukotrienes; MΦ, macrophages; NAVA, neurally adjusted ventilatory assist; PG, prostaglandins; ROS, reactive oxygen species; VILI, ventilator-induced lung injury.