Purpose: The selection and intensity of respiratory support for ARDS are guided by PaO 2/FiO2 . However, ventilator-induced lung injury (VILI) is linked to respiratory mechanics and ventilator settings. We explored whether the VILI riskis related to ARDS severity based on oxygenation.

 

Methods: We analysed data on 228 ARDS subjects with PaO 2/FiO2 < 200 mmHg, categorized into three severitygroups: one based on PaO 2 /FiO2 ratio, and the others based on tertiles of predictors of VILI: mechanical power ratio(MPR) and driving pressure (DP). In each group of oxygenation-based ARDS severity and MPR and DP tertiles, wemeasured CT anatomy, gas exchange, respiratory mechanics, VILI prerequisites (lung elastance and lung gas volume),and VILI determinants (tidal volume, PEEP, airway pressures).

 

Results: Predictors of VILI, such as MPR and DP, were similar across ARDS severity groups based on PaO 2/FiO2 ratio,while oxygenation remained comparable across different levels of VILI risk defined by MPR and DP. Oxygenationimpairment was associated with increased lung weight, recruitability, and reduced well-inflated tissue. In contrast,MPR and DP tertiles affected variables associated with the baby lung size, such as lung gas volume and well-inflatedtissue. Mechanical ventilation intensity increased progressively across MPR and DP tertiles, but remained similar acrossPaO 2/FiO2 severity groups.

 

Conclusions: ARDS severity based on oxygenation impairment does not reflect the prerequisites and determinantsof VILI. This should prompt a reconsideration of recommending respiratory support based on oxygenation impair-ment, rather than VILI determinants