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Background Insufficient or excessive respiratory effort during acute hypoxemic respiratory failure (AHRF) increases the risk of lung and diaphragm injury. We sought to establish whether respiratory effort can be optimized to achieve lung- and diaphragm-protective (LDP) targets (esophageal pressure swing − 3 to − 8 cm H 2 O; dynamic transpulmonary driving pressure ≤ 15 cm H 2 O) during AHRF. Methods In patients with early AHRF, spontaneous breathing was initiated as soon as passive ventilation was not deemed mandatory. Inspiratory pressure, sedation, positive end-expiratory pressure (PEEP), and sweep gas flow (in patients receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO)) were systematically titrated to achieve LDP targets. Additionally, partial neuromuscular blockade (pNMBA) was administered in patients with refractory excessive respiratory effort. Results Of 30 patients enrolled, most had severe AHRF; 16 required VV-ECMO. Respiratory effort was absent in all at enrolment. After initiating spontaneous breathing, most exhibited high respiratory effort and only 6/30 met LDP targets. After titrating ventilation, sedation, and sweep gas flow, LDP targets were achieved in 20/30. LDP targets were more likely to be achieved in patients on VV-ECMO (median OR 10, 95% CrI 2, 81) and at the PEEP level associated with improved dynamic compliance (median OR 33, 95% CrI 5, 898). Administration of pNMBA to patients with refractory excessive effort was well-tolerated and effectively achieved LDP targets. Conclusion Respiratory effort is frequently absent  under deep sedation but becomes excessive when spontaneous breathing is permitted in patients with moderate or severe AHRF. Systematically titrating ventilation and sedation can optimize respiratory effort for lung and diaphragm protection in most patients. VV-ECMO can greatly facilitate the delivery of a LDP strategy. Trial registration : This trial was registered in Clinicaltrials.gov in August 2018 (NCT03612583).

This study conducts a bibliometric analysis to map the intellectual structure, evolution, and emerging trends in research on airway pressure-based indexes for monitoring inspiratory effort. Systematic searches of the Web of Science Core Collection (WOSCC) and Pubmed were performed for publications dated between 1990 and 2025. Bibliometric parameters, including publication trends, country and affiliation contributions, author influence, journal distribution, keyword co-occurrence, and reference co-citation networks, were analyzed using Bibliometrix and CiteSpace. The analysis included 291 publications from WOSCC. The annual publication output showed a near U-shaped trend, with an initial decline after the 1990s, followed by a strong resurgence after 2011. Italy was the most productive country, followed by the USA and France. The Institut National de la Sante et de la Recherche Medicale emerged as the leading institution. The journal Chest published the most articles, while the American Journal of Respiratory and Critical Care Medicine had the highest total citations. Laurent Brochard was identified as the most prolific and influential author. Keyword analysis highlighted \"occlusion pressure\" and \"mechanical ventilation\" as core themes. Reference co-citation clustering revealed major research domains, including \"acute respiratory distress syndrome,\" \"self-inflicted lung injury,\" and \"nasal high flow.\" Burst detection analysis indicated that \"respiratory drive,\" \"lung injury,\" and \"critically ill patients\" are emerging research frontiers. Complementary analysis of 242 PubMed clinical studies confirmed these trends and highlighted growing clinical focus on \"fluid responsiveness\" and \"amyotrophic lateral sclerosis.\" Research on airway pressure-based indices has evolved from physiological studies into a crucial clinical tool for respiratory monitoring. The field exhibits strong international collaboration and emphasizes core areas, including acute respiratory failure and lung-protective ventilation. Analysis of clinical study data confirms these trends and highlights emerging applications in the assessment of fluid responsiveness and neuromuscular disorders. These findings support the ongoing development of personalized ventilation strategies based on monitoring respiratory effort.

Background and Objectives: Mechanical ventilation, while essential, can precipitate ventilator-induced lung injury (VILI) due to excessive mechanical stress. Among respiratory mechanics, driving pressure (ΔP) has emerged as the most robust predictor of mortality, with mechanical power (MP) and tidal volume (TV), respiratory rate (RR), positive end-expiratory pressure (PEEP), and peak inspiratory pressure (Ppeak) also potentially influencing clinical outcomes. This study primarily evaluated whether the implementation of a standardized Lung and Diaphragm Protective Ventilation (LDPV) protocol, designed to minimize ΔP, reduced intensive care unit (ICU) mortality. Secondary objectives included assessing the prognostic impact of MP, Ppeak, TV, RR, and PEEP on mortality in the pre- and post-LDPV implementation periods. Materials and Methods: In this retrospective cohort study, a total of 3468 adult ICU patients receiving invasive mechanical ventilation between 2012 and 2024 were analyzed. Patients were categorized into two groups: pre-LDPV (2012–2018) and post-LDPV (2019–2024). Ventilatory data were automatically collected using the Metavision system and evaluated through receiver operating characteristic (ROC) derived cutoffs, survival modeling, and Cox proportional hazards regression. Results: Implementation of the LDPV protocol was associated with a significant reduction in ICU mortality (47.7% vs. 41.1%, p < 0.0001) and a shorter ICU length of stay. Patients in the post-LDPV cohort (2019–2024) exhibited lower ΔP (median 12.9 vs. 14.3 cmH2O), lower MP (median 15.0 vs. 17.0 J/min), improved respiratory system compliance, and reduced peak inspiratory pressure (Ppeak) and tidal volume (TVe) compared to the pre-LDPV cohort (2012–2018). Analysis revealed that the reduction in ΔP was the most significant determinant of improved survival; median ΔP decreased by approximately 2 cmH2O (from 14.3 to 12.9 cmH2O). Elevated MP and Ppeak were also predictive of mortality, while compliance below 34 mL/cmH2O consistently indicated a poor prognosis across both study periods. Conclusions: Implementation of an LDPV protocol significantly reduced ICU mortality, primarily through the systematic reduction in ΔP, while MP and its components provided complementary prognostic information. These findings underscore ΔP as the primary modifiable determinant of survival, with MP, Ppeak, TV, and PEEP serving as secondary indicators of VILI.

Ventilator-induced lung injury and diaphragm dysfunction are well-recognized complications of mechanical ventilation and commonly attributed to inadequate ventilator settings. Excessive or insufficient assistance and the patient’s own respiratory effort are increasingly acknowledged as important factors in the pathogenesis of these injuries. Therefore, monitoring respiratory effort at the bedside is a highly relevant strategy to identify and prevent potentially injurious breathing patterns. Esophageal manometry remains the reference standard for assessing respiratory effort, but its technical complexity limits routine clinical use. Placement and calibration of the esophageal balloon are time-consuming and require specific expertise. Moreover, the invasive nature of the procedure precludes visual confirmation and leads to uncertainty about correct positioning, reducing confidence in the validity of measurements. Innovative noninvasive and continuous monitoring techniques are emerging as more accessible and scalable alternatives, enabling assessment of respiratory effort without impacting so much on clinical workflow. This narrative review provides an in-depth overview of three noninvasive techniques that are reshaping continuous respiratory effort monitoring: (1) Surface electromyography (sEMG) now enables continuous monitoring of respiratory muscle activity and derivation of continuous effort estimation using electrodes placed on the torso of the patient. (2) Computational modeling offers dynamic, patient-specific effort estimation from ventilator waveforms. (3) Assessment of diaphragm thickening fraction, derived from high-resolution ultrasound, provides a straightforward surrogate for effort, driven by widely available acquisition devices. Together, these innovations promise to make respiratory muscle monitoring less labor-intensive and more clinically sustainable—paving the way for broader implementation of diaphragm-protective ventilation strategies in critical care.

Maintaining spontaneous breathing has both potentially beneficial and deleterious consequences in patients with acute respiratory failure, depending on the balance that can be obtained between the protecting and damaging effects on the lungs and the diaphragm. Neurally adjusted ventilatory assist (NAVA) is an assist mode, which supplies the respiratory system with a pressure proportional to the integral of the electrical activity of the diaphragm. This proportional mode of ventilation has the theoretical potential to deliver lung- and respiratory-muscle-protective ventilation by preserving the physiologic defense mechanisms against both lung overdistention and ventilator overassistance, as well as reducing the incidence of diaphragm disuse atrophy while maintaining patient–ventilator synchrony. This narrative review presents an overview of NAVA technology, its basic principles, the different methods to set the assist level and the findings of experimental and clinical studies which focused on lung and diaphragm protection, machine–patient interaction and preservation of breathing pattern variability. A summary of the findings of the available clinical trials which investigate the use of NAVA in acute respiratory failure will also be presented and discussed.

Mechanical ventilation injures not only the lungs but also the diaphragm, resulting in dysfunction associated with poor outcomes. Diaphragm ultrasonography is a noninvasive, cost-effective, and reproducible diagnostic method used to monitor the condition and function of the diaphragm. With advances in ultrasound technology and the expansion of its clinical applications, diaphragm ultrasonography has become increasingly important as a tool to visualize and quantify diaphragmatic morphology and function across multiple medical specialties, including pulmonology, critical care, and rehabilitation medicine. This comprehensive review aims to provide an in-depth analysis of the role and limitations of ultrasonography in assessing the diaphragm, especially among critically ill patients. Furthermore, we discuss a recently published expert consensus and provide a perspective for the future.

Mechanical ventilation (MV) is a life-saving respiratory support therapy, but MV can lead to diaphragm muscle injury (myotrauma) and induce diaphragmatic dysfunction (DD). DD is relevant because it is highly prevalent and associated with significant adverse outcomes, including prolonged ventilation, weaning failures, and mortality. The main mechanisms involved in the occurrence of myotrauma are associated with inadequate MV support in adapting to the patient’s respiratory effort (over- and under-assistance) and as a result of patient-ventilator asynchrony (PVA). The recognition of these mechanisms associated with myotrauma forced the development of myotrauma prevention strategies (MV with diaphragm protection), mainly based on titration of appropriate levels of inspiratory effort (to avoid over- and under-assistance) and to avoid PVA. Protecting the diaphragm during MV therefore requires the use of tools to monitor diaphragmatic effort and detect PVA. Diaphragm ultrasound is a non-invasive technique that can be used to monitor diaphragm function, to assess PVA, and potentially help to define diaphragmatic effort with protective ventilation. This review aims to provide clinicians with an overview of the relevance of DD and the main mechanisms underlying myotrauma, as well as the most current strategies aimed at minimizing the occurrence of myotrauma with special emphasis on the role of ultrasound in monitoring diaphragm function.

This review explores the complex interactions between sedation and invasive ventilation and examines the potential of volatile anesthetics for lung- and diaphragm-protective sedation. In the early stages of invasive ventilation, many critically ill patients experience insufficient respiratory drive and effort, leading to compromised diaphragm function. Compared with common intravenous agents, inhaled sedation with volatile anesthetics better preserves respiratory drive, potentially helping to maintain diaphragm function during prolonged periods of invasive ventilation. In turn, higher concentrations of volatile anesthetics reduce the size of spontaneously generated tidal volumes, potentially reducing lung stress and strain and with that the risk of self-inflicted lung injury. Taken together, inhaled sedation may allow titration of respiratory drive to maintain inspiratory efforts within lung- and diaphragm-protective ranges. Particularly in patients who are expected to require prolonged invasive ventilation, in whom the restoration of adequate but safe inspiratory effort is crucial for successful weaning, inhaled sedation represents an attractive option for lung- and diaphragm-protective sedation. A technical limitation is ventilatory dead space introduced by volatile anesthetic reflectors, although this impact is minimal and comparable to ventilation with heat and moisture exchangers. Further studies are imperative for a comprehensive understanding of the specific effects of inhaled sedation on respiratory drive and effort and, ultimately, how this translates into patient-centered outcomes in critically ill patients. Graphical abstract

Background Every year, more than 2.5 million critically ill patients in the ICU are dependent on mechanical ventilation. The positive pressure in the lungs generated by the ventilator keeps the diaphragm passive, which can lead to a loss of myofibers within a short time. To prevent ventilator-induced diaphragmatic dysfunction (VIDD), phrenic nerve stimulation may be used. Objective The goal of this study is to show the feasibility of transesophageal phrenic nerve stimulation (TEPNS). We hypothesize that selective phrenic nerve stimulation can efficiently activate the diaphragm with reduced co-stimulations. Methods An in vitro study in saline solution combined with anatomical findings was performed to investigate relevant stimulation parameters such as inter-electrode spacing, range to target site, or omnidirectional vs. sectioned electrodes. Subsequently, dedicated esophageal electrodes were inserted into a pig and single stimulation pulses were delivered simultaneously with mechanical ventilation. Various stimulation sites and response parameters such as transdiaphragmatic pressure or airway flow were analyzed to establish an appropriate stimulation setting. Results Phrenic nerve stimulation with esophageal electrodes has been demonstrated. With a current amplitude of 40 mA, similar response figures of the diaphragm activation as compared to conventional stimulation with needle electrodes at 10mA were observed. Directed electrodes best aligned with the phrenic nerve resulted in up to 16.9 % higher amplitude at the target site in vitro and up to 6 cmH20 higher transdiaphragmatic pressure in vivo as compared to omnidirectional electrodes. The activation efficiency was more sensitive to the stimulation level inside the esophagus than to the inter-electrode spacing. Most effective and selective stimulation was achieved at the level of rib 1 using sectioned electrodes 40 mm apart. Conclusion Directed transesophageal phrenic nerve stimulation with single stimuli enabled diaphragm activation. In the future, this method might keep the diaphragm active during, and even support, artificial ventilation. Meanwhile, dedicated sectioned electrodes could be integrated into gastric feeding tubes.