Lung- and Diaphragm-Protective Ventilation
Ewan Goligher
(1, 2)
,
Martin Dres
(3, 4)
,
Bhakti Patel
(5)
,
Sarina Sahetya
(6)
,
Jeremy Beitler
(7)
,
Irene Telias
(1, 8)
,
Takeshi Yoshida
(9)
,
Katerina Vaporidi
(10)
,
Domenico Luca Grieco
(11, 12)
,
Tom Schepens
(13)
,
Giacomo Grasselli
(14, 15)
,
Savino Spadaro
(16)
,
Jose Dianti
(1, 17)
,
Marcelo Amato
(18)
,
Giacomo Bellani
(19)
,
Alexandre Demoule
(3, 4)
,
Eddy Fan
(1, 2, 20)
,
Niall Ferguson
(1, 2, 20)
,
Dimitrios Georgopoulos
(10)
,
Claude Guérin
(21, 22)
,
Robinder Khemani
(23, 24)
,
Franco Laghi
(25)
,
Alain Mercat
(26)
,
Francesco Mojoli
(27)
,
Coen Ottenheijm
(28)
,
Samir Jaber
(29, 30)
,
Leo Heunks
(28)
,
Jordi Mancebo
(31)
,
Tommaso Mauri
(12, 13)
,
Antonio Pesenti
(12, 13)
,
Laurent Brochard
(8)
1
University Health Network [Toronto, ON, Canada]
2 TGHRI - Toronto General Hospital Research Institute [Canada]
3 UMRS 1158 - Neurophysiologie Respiratoire Expérimentale et Clinique
4 CHU Pitié-Salpêtrière [AP-HP]
5 University of Chicago
6 JHU - Johns Hopkins University
7 Columbia University [New York]
8 St. Michael's Hospital
9 Osaka University
10 UOC - University of Crete [Heraklion]
11 Unicatt - Università cattolica del Sacro Cuore = Catholic University of the Sacred Heart [Roma]
12 Fondazione Policlinico Universitario Agostino Gemelli IRCCS
13 UZA - Antwerp University Hospital [Edegem]
14 Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico
15 UNIMI - Università degli Studi di Milano = University of Milan
16 UniFE - Università degli Studi di Ferrara = University of Ferrara
17 Italian Hospital of Buenos Aires
18 USP - Universidade de São Paulo = University of São Paulo
19 UNIMIB - Università degli Studi di Milano-Bicocca = University of Milano-Bicocca
20 University of Toronto
21 Hôpital Edouard Herriot [CHU - HCL]
22 Inserm U955 - Molecular virology and immunology – Physiopathology and therapeutic of chronic viral hepatitis (Team 18)
23 Children’s Hospital Los Angeles [Los Angeles]
24 USC - University of Southern California
25 Loyola University [Chicago]
26 Endocrinologie pédiatrique[CHU Angers]
27 UNIPV - Università degli Studi di Pavia [Italia] = University of Pavia [Italy] = Université de Pavie [Italie]
28 Amsterdam UMC - Amsterdam University Medical Centers
29 Hôpital Saint Eloi [CHU Montpellier]
30 PhyMedExp - Physiologie & médecine expérimentale du Cœur et des Muscles [U 1046]
31 Hospital de la Santa Creu i Sant Pau
2 TGHRI - Toronto General Hospital Research Institute [Canada]
3 UMRS 1158 - Neurophysiologie Respiratoire Expérimentale et Clinique
4 CHU Pitié-Salpêtrière [AP-HP]
5 University of Chicago
6 JHU - Johns Hopkins University
7 Columbia University [New York]
8 St. Michael's Hospital
9 Osaka University
10 UOC - University of Crete [Heraklion]
11 Unicatt - Università cattolica del Sacro Cuore = Catholic University of the Sacred Heart [Roma]
12 Fondazione Policlinico Universitario Agostino Gemelli IRCCS
13 UZA - Antwerp University Hospital [Edegem]
14 Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico
15 UNIMI - Università degli Studi di Milano = University of Milan
16 UniFE - Università degli Studi di Ferrara = University of Ferrara
17 Italian Hospital of Buenos Aires
18 USP - Universidade de São Paulo = University of São Paulo
19 UNIMIB - Università degli Studi di Milano-Bicocca = University of Milano-Bicocca
20 University of Toronto
21 Hôpital Edouard Herriot [CHU - HCL]
22 Inserm U955 - Molecular virology and immunology – Physiopathology and therapeutic of chronic viral hepatitis (Team 18)
23 Children’s Hospital Los Angeles [Los Angeles]
24 USC - University of Southern California
25 Loyola University [Chicago]
26 Endocrinologie pédiatrique[CHU Angers]
27 UNIPV - Università degli Studi di Pavia [Italia] = University of Pavia [Italy] = Université de Pavie [Italie]
28 Amsterdam UMC - Amsterdam University Medical Centers
29 Hôpital Saint Eloi [CHU Montpellier]
30 PhyMedExp - Physiologie & médecine expérimentale du Cœur et des Muscles [U 1046]
31 Hospital de la Santa Creu i Sant Pau
Ewan Goligher
- Fonction : Auteur
- PersonId : 812399
- ORCID : 0000-0002-0990-6701
Giacomo Grasselli
- Fonction : Auteur
- PersonId : 1226540
- ORCID : 0000-0002-1735-1400
Jose Dianti
- Fonction : Auteur
- PersonId : 1226541
- ORCID : 0000-0003-2016-7003
Giacomo Bellani
- Fonction : Auteur
- PersonId : 791055
- ORCID : 0000-0002-3089-205X
Claude Guérin
- Fonction : Auteur
- PersonId : 756209
- ORCID : 0000-0003-4700-6672
- IdRef : 026906376
Résumé
Mechanical ventilation can cause acute diaphragm atrophy and injury, and this is associated with poor clinical outcomes. Although the importance and impact of lung-protective ventilation is widely appreciated and well established, the concept of diaphragm-protective ventilation has recently emerged as a potential complementary therapeutic strategy. This Perspective, developed from discussions at a meeting of international experts convened by PLUG (the Pleural Pressure Working Group) of the European Society of Intensive Care Medicine, outlines a conceptual framework for an integrated lung- and diaphragm-protective approach to mechanical ventilation on the basis of growing evidence about mechanisms of injury. We propose targets for diaphragm protection based on respiratory effort and patient-ventilator synchrony. The potential for conflict between diaphragm protection and lung protection under certain conditions is discussed; we emphasize that when conflicts arise, lung protection must be prioritized over diaphragm protection. Monitoring respiratory effort is essential to concomitantly protect both the diaphragm and the lung during mechanical ventilation. To implement lung- and diaphragm-protective ventilation, new approaches to monitoring, to setting the ventilator, and to titrating sedation will be required. Adjunctive interventions, including extracorporeal life support techniques, phrenic nerve stimulation, and clinical decision-support systems, may also play an important role in selected patients in the future. Evaluating the clinical impact of this new paradigm will be challenging, owing to the complexity of the intervention. The concept of lung- and diaphragm-protective ventilation presents a new opportunity to potentially improve clinical outcomes for critically ill patients.