Lung- and Diaphragm-Protective Ventilation
Por:
Goligher, EC, Dres, M, Patel, BK, Sahetya, SK, Beitler, JR, Telias, I, Yoshida, T, Vaporidi, K, Grieco, DL, Schepens, T, Grasselli, G, Spadaro, S, Dianti, J, Amato, M, Bellani, G, Demoule, A, Fan, E, Ferguson, ND, Georgopoulos, D, Guerin, C, Khemani, RG, Laghi, F, Mercat, A, Mojoli, F, Ottenheijm, CAC, Jaber, S, Heunks, L, Mancebo, J, Mauri, T, Pesenti, A, Brochard, L, European Soc Intensive Care Med
Publicada:
1 oct 2020
Resumen:
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.
Filiaciones:
Goligher, EC:
Univ Toronto, Interdept Div Crit Care Med, Toronto, ON, Canada
Univ Hlth Network, Dept Med, Div Respirol, Toronto, ON, Canada
Toronto Gen Hosp Res Inst, Toronto, ON, Canada
Dres, M:
Sorbonne Univ, Grp Hosp Univ, AP HP, Serv Pneumol Med Intens & Reanimat,Dept R3S,Site, Paris, France
Sorbonne Univ, INSERM, Unite Mixte Rech Sorbonne 1158 Neurophysiol Resp, Paris, France
Patel, BK:
Univ Chicago, Dept Med, Sect Pulm & Crit Care, 5841 S Maryland Ave, Chicago, IL 60637 USA
Sahetya, SK:
Johns Hopkins Univ, Sch Med, Div Pulm & Crit Care Med, Baltimore, MD USA
Beitler, JR:
Columbia Univ Coll Phys & Surg, Div Pulm Allergy & Crit Care Med, Ctr Acute Resp Failure, 630 W 168th St, New York, NY 10032 USA
Telias, I:
Univ Toronto, Interdept Div Crit Care Med, Toronto, ON, Canada
Univ Hlth Network, Dept Med, Div Respirol, Toronto, ON, Canada
St Michaels Hosp, Li Ka Shing Knowledge Inst, Keenan Ctr Biomed Res, Toronto, ON, Canada
Yoshida, T:
Osaka Univ, Grad Sch Med, Dept Anesthesiol & Intens Care Med, Suita, Osaka, Japan
Vaporidi, K:
Univ Crete, Univ Hosp Heraklion, Med Sch, Dept Intens Care Med, Iraklion, Greece
Grieco, DL:
Univ Cattolica Sacro Cuore, Dept Anesthesiol & Intens Care Med, Rome, Italy
Fdn Policlin Univ, A Gemelli Ist Ricovero & Cura Carattere Sci, Dipartimento Med Urgenza & Terapia Intens & Anest, Rome, Italy
Schepens, T:
Antwerp Univ Hosp, Dept Crit Care Med, Antwerp, Belgium
Grasselli, G:
Fdn Ist Ricovero & Cura Carattere Sci Ca Granda O, Dept Anesthesiol Intens Care & Emergency, Milan, Italy
Univ Milan, Dept Pathophysiol & Transplantat, Milan, Italy
Spadaro, S:
Univ Ferrara, ICU, St Annes Archbishop Hosp, Dept Morphol Surg & Expt Med, Ferrara, Italy
Dianti, J:
Univ Toronto, Interdept Div Crit Care Med, Toronto, ON, Canada
Univ Hlth Network, Dept Med, Div Respirol, Toronto, ON, Canada
Italian Hosp Buenos Aires, Dept Med, Intens Care Unit, Buenos Aires, DF, Argentina
Amato, M:
Univ Sao Paulo, Hosp Clin, Inst Coracao, Disciplina Pneumol,Fac Med,Lab Pneumol,Lab Invest, Sao Paulo, Brazil
Bellani, G:
Univ Milano Bicocca, Dept Med & Surg, Monza, Italy
Demoule, A:
Sorbonne Univ, Grp Hosp Univ, AP HP, Serv Pneumol Med Intens & Reanimat,Dept R3S,Site, Paris, France
Sorbonne Univ, INSERM, Unite Mixte Rech Sorbonne 1158 Neurophysiol Resp, Paris, France
Fan, E:
Univ Toronto, Interdept Div Crit Care Med, Toronto, ON, Canada
Univ Toronto, Inst Hlth Policy Management & Evaluat, Toronto, ON, Canada
Univ Hlth Network, Dept Med, Div Respirol, Toronto, ON, Canada
Toronto Gen Hosp Res Inst, Toronto, ON, Canada
Ferguson, ND:
Univ Toronto, Interdept Div Crit Care Med, Toronto, ON, Canada
Univ Toronto, Inst Hlth Policy Management & Evaluat, Toronto, ON, Canada
Univ Toronto, Dept Physiol, Toronto, ON, Canada
Univ Hlth Network, Dept Med, Div Respirol, Toronto, ON, Canada
Toronto Gen Hosp Res Inst, Toronto, ON, Canada
Georgopoulos, D:
Univ Crete, Univ Hosp Heraklion, Med Sch, Dept Intens Care Med, Iraklion, Greece
Guerin, C:
Univ Lyon, Med Intens Reanimat, Hop Edouard Herriot Lyon, Fac Med Lyon Est,Inst Natl Sante & Rech Med 955 C, Lyon, France
Khemani, RG:
Childrens Hosp Los Angeles, Dept Anesthesiol & Crit Care, Los Angeles, CA 90027 USA
Univ Southern Calif, Dept Pediat, Los Angeles, CA 90007 USA
Laghi, F:
Loyola Univ, Stritch Sch Med, Div Pulm & Crit Care Med, 2160 S 1st Ave, Maywood, IL 60153 USA
Hines Vet Affairs Hosp, Div Pulm & Crit Care Med, Hines, IL USA
Mercat, A:
Ctr Hosp Angers, Dept Med Intens Reanimat & Med Hyperbare, Angers, France
Mojoli, F:
Univ Pavia, Sci Hospitalizat & Care Inst, San Matteo Polyclin Fdn, Dept Anesthesia & Intens Care, Pavia, Italy
Ottenheijm, CAC:
Univ Amsterdam, Med Ctr, Vrije Univ Locat, Dept Physiol, Amsterdam, Netherlands
Jaber, S:
Univ Montpellier, Anesthesiol & Intens Care Anesthesia & Crit Care, St Eloi Teaching Hosp,Natl Inst Hlth & Med Res U1, PhyMedExp,Montpellier Univ Hosp Ctr,Joint Res Uni, Montpellier, France
Heunks, L:
Univ Amsterdam, Med Ctr, Vrije Univ Locat, Dept Intens Care, Amsterdam, Netherlands
Mancebo, J:
Hosp Santa Creu & Sant Pau, Serv Med Intens, Barcelona, Spain
Mauri, T:
Fdn Policlin Univ, A Gemelli Ist Ricovero & Cura Carattere Sci, Dipartimento Med Urgenza & Terapia Intens & Anest, Rome, Italy
Antwerp Univ Hosp, Dept Crit Care Med, Antwerp, Belgium
Pesenti, A:
Fdn Policlin Univ, A Gemelli Ist Ricovero & Cura Carattere Sci, Dipartimento Med Urgenza & Terapia Intens & Anest, Rome, Italy
Antwerp Univ Hosp, Dept Crit Care Med, Antwerp, Belgium
Brochard, L:
Univ Toronto, Interdept Div Crit Care Med, Toronto, ON, Canada
St Michaels Hosp, Li Ka Shing Knowledge Inst, Keenan Ctr Biomed Res, Toronto, ON, Canada
Green Submitted, Green Published
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