ICU · respiratory
Ventilator-Induced Lung Injury (VILI) — Mechanisms and Prevention
Also known as VILI · Ventilator-induced lung injury · Volutrauma · Atelectrauma · Barotrauma · Biotrauma · Lung-protective ventilation · Driving pressure · Transpulmonary pressure · Pendelluft
Ventilator-induced lung injury (VILI) — the lung damage caused by mechanical ventilation itself, distinct from the underlying disease process. Four mechanisms: (1) Volutrauma (alveolar overdistension from excessive tidal volume or transpulmonary pressure → epithelial/endothelial disruption → inflammation), (2) Atelectrauma (repeated cyclic opening and closing of recruitable alveoli at low end-expiratory pressure → shear stress → injury), (3) Barotrauma (alveolar rupture from excessive airway pressure → pneumothorax, pneumomediastinum, subcutaneous emphysema), (4) Biotrauma (release of inflammatory mediators [cytokines, chemokines] from mechanically stressed lung → systemic spillover → MODS). Prevention: lung-protective ventilation — Vt 4-6 mL/kg predicted body weight, plateau pressure <30 cmH2O, driving pressure (delta P = Pplat - PEEP) <15 cmH2O, PEEP optimised to avoid atelectrauma, permissive hypercapnia. Additional targets: transpulmonary pressure (PL = Pairway - P_esophageal) — oesophageal balloon manometry guides PEEP titration in obese/ARDS patients. The ARDSNet trial (2000) established Vt 6 mL/kg as standard — 22% relative mortality reduction vs 12 mL/kg. VILI is NOT limited to ARDS — it occurs in ANY mechanically ventilated patient — apply lung-protective ventilation universally.
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- Driving pressure (delta P = Pplat - PEEP) is the ventilation variable MOST strongly associated with survival in ARDS — stronger than tidal volume or plateau pressure alone — minimise it
- Tidal volume 6 mL/kg is calculated from PREDICTED body weight (based on height and sex), NOT actual body weight — using actual weight in an obese patient OVERDOSES the tidal volume → volutrauma
- PEEP must be OPTIMISED — too low → atelectrauma (repeated alveolar collapse/reopening); too high → volutrauma (overdistension) + haemodynamic compromise (reduced venous return) — there is NO universal optimal PEEP — titrate per patient
- Plateau pressure >30 cmH2O is associated with increased mortality — but this is a SURROGATE for transpulmonary pressure — a high plateau in a patient with a stiff chest wall (obesity, kyphoscoliosis, abdominal compartment syndrome) may be SAFE because the transpulmonary pressure is not elevated
- Pendelluft — intrapulmonary gas shifting from non-dependent to dependent lung regions during inspiration → overdistension of dependent lung even with 'safe' tidal volumes — relevant in asymmetrical lung disease (unilateral pneumonia, lobar consolidation)
Overview
[1]References21ShowHide
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