Advances in achieving lung and diaphragm-protective ventilation

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Summary of “Advances in achieving lung and diaphragm-protective ventilation”

Abstract

Mechanical ventilation, while lifesaving, poses risks to both lung and diaphragm integrity. This review discusses the latest evidence and technologies for monitoring and interventions that support the combined goal of lung- and diaphragm-protective ventilation (LDPV). It emphasizes noninvasive bedside strategies, optimal titration of ventilator support, and emerging techniques such as extracorporeal CO₂ removal, neuromechanical uncoupling, and phrenic nerve stimulation. The article calls for individualized care guided by physiologic insights and proposes a practical bedside protocol.

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Monitoring parameters and interventions to achieve lung- and diaphragm-protective ventilation. Schematic representation of the monitoring parameters and interventions available to achieve lung- and diaphragm-protective ventilation in relation to the time course of respiratory failure and ventilatory support. In the early/acute phase of respiratory failure, lung-protective ventilation should be given priority, thereafter this priority gradually shifts to diaphragm-protective ventilation. Dashed arrows indicate experimental interventions that should not routinely be used in clinical practice. ΔPaw, airway driving pressure; ΔPdi, transdiaphragmatic pressure swing; ΔPL, static transpulmonary driving pressure; ΔPL,dyn, dynamic transpulmonary driving pressure; ΔPmus, respiratory muscle pressure swing; EAdi, electrical activity of the diaphragm; EIT, electrical impedance tomography; HFNO, high-flow nasal oxygen; NIV, noninvasive ventilation; NMBA, neuromuscular blocking agents; NRD, neural respiratory drive; PEEP, positive end-expiratory pressure; PMI, pressure muscle index; Pocc, airway occlusion pressure; SGF, sweep gas flow; TFdi, diaphragm thickening fraction; VT, tidal volume. vv-ECMO, veno-venous extracorporeal membrane oxygenation.

10 Key Points

  1. Dual Threat of Mechanical Ventilation: Ventilator-induced lung injury (VILI) and diaphragm disuse atrophy (VIDD) can occur simultaneously. Strategies must balance minimizing lung stress with preserving diaphragm activity.

  2. Critical Monitoring Parameters: Noninvasive indices such as P0.1, Pocc, and pressure muscle index (PMI) effectively reflect patient effort and lung stress. Advanced methods include esophageal manometry, diaphragm ultrasound, and electrical impedance tomography (EIT).

  3. Safe Target Ranges: The authors provide consensus-based thresholds for key respiratory variables (e.g., tidal volume, P0.1, Pocc, DPaw, DPL, TFdi) that help identify excessive effort, over-assistance, and lung stress.

  4. Transition from Controlled to Assisted Ventilation: This period is especially vulnerable to patient-ventilator dyssynchrony and excessive diaphragm strain. Close monitoring and titration of sedation and inspiratory support are essential.

  5. PEEP as a Modulator: PEEP adjustments can either reduce or exacerbate respiratory effort depending on lung mechanics. Improper PEEP may flatten the diaphragm or induce eccentric contractions, emphasizing the need for individualized titration.

  6. Extracorporeal CO₂ Removal (ECCO₂R): Modulating sweep gas flow can reduce neural respiratory drive. While promising in early studies, ECCO₂R is best used adjunctively after optimizing other ventilator settings.

  7. Partial Neuromuscular Blockade & Nerve Block: Low-dose rocuronium or phrenic nerve block can selectively uncouple diaphragmatic contraction from neural drive. While effective short-term, the safety of prolonged use remains uncertain.

  8. Diaphragm Neurostimulation: Electrical or magnetic stimulation of the phrenic nerve is a promising but still experimental technique aimed at preventing disuse atrophy and improving regional lung aeration.

  9. Bedside Protocol Using Pocc: A practical stepwise approach incorporates Pocc to estimate both lung stress and diaphragm effort, guiding adjustments in sedation and ventilatory support to remain within protective zones.

  10. Call for Multi-Modal Interventions: Single interventions are insufficient. Combining monitoring with sedation management, ventilator titration, PEEP optimization, and—when needed—advanced techniques like ECCO₂R or stimulation provides the most promise for true LDPV.

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Bedside approach to achieve lung- and diaphragm-protective ventilation based on the occluded inspiratory airway pressure. In this approach the occluded inspiratory airway pressure (Pocc) is measured to estimate both lung stress and diaphragm effort. Pinsp is the inspiratory pressure set on the ventilator without including the rise in pressure that can sometimes be observed during the latter part of inspiration. The protocol can be repeated hourly, or when patient breathing effort has likely changed such as after changing ventilator settings. Note that prospective studies are required to assess whether using this protocol results in lung stress and effort in purported safe ranges. Figure adapted from [14▪▪].

Conclusion

Achieving lung- and diaphragm-protective ventilation is a dynamic, multifaceted process requiring individualized assessment and intervention. Success hinges on understanding the pathophysiologic balance between respiratory muscle activity and lung mechanics. Bedside tools such as Pocc and esophageal pressure monitoring, combined with rational adjustments in sedation, ventilator settings, and adjunctive support like ECCO₂R, may bridge the gap between physiologic targets and clinical feasibility. More prospective studies are needed to validate long-term outcomes of these strategies.

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Advances in achieving lung and diaphragm-protective ventilation

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