Innovations in protective mechanical ventilation for acute respiratory distress syndrome management

Introduction

Managing acute respiratory distress syndrome (ARDS) poses significant challenges due to its heterogeneous nature. As of 2024, the updated global definition of ARDS now includes patients receiving noninvasive ventilation or high-flow oxygen therapy, facilitating earlier diagnosis [Citation1]. Despite advancements in identifying ARDS sub-phenotypes, integration of these novel entities into clinical practice remains uncertain. Moreover, effective therapies for ARDS are limited, with persistently high mortality rates [Citation2].

Supportive therapies are now considered the cornerstone of ARDS management, with lung-protective mechanical ventilation (MV) playing a pivotal role. Lung-protective MV improves survival in ARDS by employing strategies such as a sufficiently low tidal volume (VT) [4–8 mL/kg of predicted body weight (PBW)] with low driving pressure (ΔP) (<15 cmH2O), low plateau pressure (Pplat) (<30 cmH2O), moderate-to-high levels of positive end-expiratory pressure (PEEP), and prone positioning [Citation1,Citation3]. Additional variables (such as energy and mechanical power derived from individual parameters) appear promising to inform tailored MV settings, although their impact on patient outcomes remains to be fully elucidated [Citation4].

Given the limited and uncertain panorama of pharmacological therapies for ARDS, innovative ventilation systems offer potential to optimize MV strategies. It is time to move beyond the traditional ‘one size fits all’ approach in MV and consider inter-individual variability to mitigate lung stress, strain, and inhomogeneity.

Innovations in MV for ARDS encompass emerging technologies aimed at improving patient outcomes through personalized ventilation strategies based on individual patient characteristics and optimized ventilation parameters. These innovations include personalized MV settings that may be tailored to sub-phenotypes, heart-lung interactions, and closed-loop or automated control systems, among others.

In this editorial, we aim to summarize the most promising innovations in protective MV for patients with ARDS.