Personalized mechanical ventilation in acute respiratory distress syndrome

Paolo Pelosi^{1

2}, Lorenzo Ball^{3

4}, Carmen S V Barbas^{5

6}, Rinaldo Bellomo^{7

8

9

10

11}, Karen E A Burns^{12

13}, Sharon Einav¹⁴, Luciano Gattinoni¹⁵, John G Laffey¹⁶, John J Marini¹⁷, Sheila N Myatra¹⁸, Marcus J Schultz^{19

20

21}, Jean Louis Teboul²², Patricia R M Rocco²³

Affiliations

¹ Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy. ppelosi@hotmail.com.
² Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy. ppelosi@hotmail.com.
³ Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
⁴ Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy.
⁵ Pneumology and Intensive Care Medicine, University of São Paulo, São Paulo, Brazil.
⁶ Adult Intensive Care Unit, Albert Einstein Hospital, São Paulo, Brazil.
⁷ Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.
⁸ Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia.
⁹ Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia.
¹⁰ Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia.
¹¹ Department of Critical Care, The University of Melbourne, Melbourne, Australia.
¹² Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
¹³ Unity Health Toronto-St. Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, ON, Canada.
¹⁴ Intensive Care Unit of the Shaare Zedek Medical Medical Centre, Hebrew University Faculty of Medicine, Jerusalem, Israel.
¹⁵ Department of Anaesthesiology, Emergency, and Intensive Care Medicine, University of Göttingen, Göttingen, Germany.
¹⁶ Anaesthesia and Intensive Care Medicine, University Hospital Galway, and School of Medicine, National University of Ireland, Galway, Ireland.
¹⁷ University of Minnesota and Regions Hospital, St. Paul, MN, USA.
¹⁸ Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
¹⁹ Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.
²⁰ Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
²¹ Nuffield Department of Medicine, University of Oxford, Oxford, UK.
²² Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, Inserm UMR S_999, AP-HP Université Paris-Saclay, Le Kremlin-Bicêtre, France.
²³ Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.

PMID: 34271958
PMCID: PMC8284184
DOI: 10.1186/s13054-021-03686-3

Review

Personalized mechanical ventilation in acute respiratory distress syndrome

Paolo Pelosi et al. Crit Care. 2021.

. 2021 Jul 16;25(1):250.

doi: 10.1186/s13054-021-03686-3.

Authors

Affiliations

¹ Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy. ppelosi@hotmail.com.
² Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy. ppelosi@hotmail.com.
³ Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
⁴ Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy.
⁵ Pneumology and Intensive Care Medicine, University of São Paulo, São Paulo, Brazil.
⁶ Adult Intensive Care Unit, Albert Einstein Hospital, São Paulo, Brazil.
⁷ Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.
⁸ Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia.
⁹ Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia.
¹⁰ Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia.
¹¹ Department of Critical Care, The University of Melbourne, Melbourne, Australia.
¹² Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
¹³ Unity Health Toronto-St. Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, ON, Canada.
¹⁴ Intensive Care Unit of the Shaare Zedek Medical Medical Centre, Hebrew University Faculty of Medicine, Jerusalem, Israel.
¹⁵ Department of Anaesthesiology, Emergency, and Intensive Care Medicine, University of Göttingen, Göttingen, Germany.
¹⁶ Anaesthesia and Intensive Care Medicine, University Hospital Galway, and School of Medicine, National University of Ireland, Galway, Ireland.
¹⁷ University of Minnesota and Regions Hospital, St. Paul, MN, USA.
¹⁸ Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
¹⁹ Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.
²⁰ Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
²¹ Nuffield Department of Medicine, University of Oxford, Oxford, UK.
²² Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, Inserm UMR S_999, AP-HP Université Paris-Saclay, Le Kremlin-Bicêtre, France.
²³ Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.

PMID: 34271958
PMCID: PMC8284184
DOI: 10.1186/s13054-021-03686-3

Abstract

A personalized mechanical ventilation approach for patients with adult respiratory distress syndrome (ARDS) based on lung physiology and morphology, ARDS etiology, lung imaging, and biological phenotypes may improve ventilation practice and outcome. However, additional research is warranted before personalized mechanical ventilation strategies can be applied at the bedside. Ventilatory parameters should be titrated based on close monitoring of targeted physiologic variables and individualized goals. Although low tidal volume (V_T) is a standard of care, further individualization of V_T may necessitate the evaluation of lung volume reserve (e.g., inspiratory capacity). Low driving pressures provide a target for clinicians to adjust V_T and possibly to optimize positive end-expiratory pressure (PEEP), while maintaining plateau pressures below safety thresholds. Esophageal pressure monitoring allows estimation of transpulmonary pressure, but its use requires technical skill and correct physiologic interpretation for clinical application at the bedside. Mechanical power considers ventilatory parameters as a whole in the optimization of ventilation setting, but further studies are necessary to assess its clinical relevance. The identification of recruitability in patients with ARDS is essential to titrate and individualize PEEP. To define gas-exchange targets for individual patients, clinicians should consider issues related to oxygen transport and dead space. In this review, we discuss the rationale for personalized approaches to mechanical ventilation for patients with ARDS, the role of lung imaging, phenotype identification, physiologically based individualized approaches to ventilation, and a future research agenda.

Keywords: Biomarkers; Chest computed tomography scan; Driving pressure; Phenotype; Tidal volume; Transpulmonary pressure.

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Conflict of interest statement

JL discloses consultancy fees for Baxter and GlaxoSmithKline. JLT is member of the medical advisory board of Getinge. KB holds a Physician Services Incorporated Mid-Career Award. MJS has received speaker-fees from Hamilton Medical. JL has received consultancy fees from Baxter and Glaxosmithkline. All other authors declare no conflict of interest.

Figures

**Fig. 1**
Summary of recommendations. V_T: tidal volume; ΔP: driving pressure; PEEP: positive end-expiratory pressure; EELV: end-expiratory lung volume; IC: inspiratory capacity; AI: artificial intelligence; P_PLAT: plateau pressure; VILI: ventilator-induced lung injury

See this image and copyright information in PMC

References

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Personalized mechanical ventilation in acute respiratory distress syndrome

Affiliations

Personalized mechanical ventilation in acute respiratory distress syndrome

Authors

Affiliations

Abstract

Conflict of interest statement

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