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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).

Neuromuscular blocking agents (NMBAs) inhibit patient-initiated active breath and the risk of high tidal volumes and consequent high transpulmonary pressure swings, and minimize patient/ ventilator asynchrony in acute respiratory distress syndrome (ARDS). Minimization of volutrauma and ventilator-induced lung injury (VILI) results in a lower incidence of barotrauma, improved oxygenation and a decrease in circulating proinflammatory markers. Recent randomized clinical trials did not reveal harmful muscular effects during a short course of NMBAs. The use of NMBAs should be considered during the early phase of severe ARDS for patients to facilitate lung protective ventilation or prone positioning only after optimising mechanical ventilation and sedation. The use of NMBAs should be integrated in a global strategy including the reduction of tidal volume, the rational use of PEEP, prone positioning and the use of a ventilatory mode allowing spontaneous ventilation as soon as possible. Partial neuromuscular blockade should be evaluated in future trials.

Background Lung–protective ventilation (LPV) has been found to minimize the risk of ventilator–induced lung injury (VILI). However, whether LPV is able to diminish ventilator–induced diaphragm dysfunction (VIDD) remains unknown. This study was designed to test the hypothesis that LPV protects the diaphragm against VIDD. Methods Adult male Wistar rats received either conventional mechanical (tidal volume [V T ]: 10 ml/kg, positive end–expiratory pressure [PEEP]: 2 cm H 2 O; CV group) or lung-protective (V T : 5 ml/kg, PEEP: 10 cm H 2 O; LPV group) ventilation for 12 h. Then, diaphragms and lungs were collected for biochemical and histological analyses. Transcriptome sequencing (RNA–seq) was performed to determine the differentially expressed genes in the diaphragms between groups. Results Our results suggested that LPV was associated with diminished pulmonary injuries and reduced oxidative stress compared with the effects of the CV strategy in rats. However, animals that received LPV showed increased protein degradation, decreased cross–sectional areas (CSAs) of myofibers, and reduced forces of the diaphragm compared with the same parameters in animals receiving CV ( p  < 0.05). In addition, the LPV group showed a higher level of oxidative stress in the diaphragm than the CV group ( p  < 0.05). Moreover, RNA–seq and western blots revealed that the peroxisome proliferator–activated receptor γ coactivator–1alpha (PGC–1α), a powerful reactive oxygen species (ROS) inhibitor, was significantly downregulated in the LPV group compared with its expression in the CV group ( p  < 0.05). Conclusions Compared with the CV strategy, the LPV strategy did not protect the diaphragm against VIDD in rats. In contrast, the LPV strategy worsened VIDD by inducing oxidative stress together with the downregulation of PGC–1α in the diaphragm. However, further studies are required to determine the roles of PGC–1α in ventilator-induced diaphragmatic oxidative stress.

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.

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.

In ARDS patients, the change from supine to prone position generates a more even distribution of the gas–tissue ratios along the dependent–nondependent axis and a more homogeneous distribution of lung stress and strain. The change to prone position is generally accompanied by a marked improvement in arterial blood gases, which is mainly due to a better overall ventilation/perfusion matching. Improvement in oxygenation and reduction in mortality are the main reasons to implement prone position in patients with ARDS. The main reason explaining a decreased mortality is less overdistension in non-dependent lung regions and less cyclical opening and closing in dependent lung regions. The only absolute contraindication for implementing prone position is an unstable spinal fracture. The maneuver to change from supine to prone and vice versa requires a skilled team of 4–5 caregivers. The most frequent adverse events are pressure sores and facial edema. Recently, the use of prone position has been extended to non-intubated spontaneously breathing patients affected with COVID-19 ARDS. The effects of this intervention on outcomes are still uncertain.

Background： Over the years, the mechanical ventilation （MV） strategy has changed worldwide. The aim of the present study was to describe the ventilation practices, particularly lung-protective ventilation （LPV）, among brain-injured patients in China. Methods： This study was a multicenter, 1-day, cross-sectional study in 47 Intensive Care Units （ICUs） across China. Mechanically ventilated patients （18 years and older） with brain injury in a participating ICU during the time of the study, including traumatic brain injury, stroke, postoperation with intracranial tumor, hypoxic-ischemic encephalopathy, intracranial infection, and idiopathic epilepsy, were enrolled. Demographic data, primary diagnoses, indications for MV, MV modes and settings, and prognoses on the 60th day were collected. Multivariable logistic analysis was used to assess factors that might affect the use of LPV. Results： A total of 104 patients were enrolled in the present study, 87 （83.7%） of whom were identified with severe brain injury based on a Glasgow Coma Scale 〈8 points. Synchronized intermittent mandatory ventilation （SIMV） was the most frequent ventilator mode, accounting for 46.2% of the entire cohort. The median tidal volume was set to 8.0 ml/kg （interquartile range [IQR], 7.0-8.9 ml/kg） of the predicted body weight; 50 （48.1%） patients received LPV. The median positive end-expiratory pressure （PEEP） was set to 5 cmH20 （IQR, 5-5 cmH20）. No PEEP values were higher than 10 cmH20. Compared with partially mandatory ventilation, supportive and spontaneous ventilation practices were associated with LPV. There were no significant differences in mortality and MV duration between patients subjected to LPV and those were not. Conclusions： Among brain-injured patients in China, SIMV was the most frequent ventilation mode. Nearly one-half of the brain-injured patients received LPV. Patients under supportive and spontaneous ventilation were more likely to receive LPV.

Background Mechanical power (MP) is the energy delivered to the respiratory system over time during mechanical ventilation. Our aim was to compare the currently available methods to calculate MP during volume- and pressure-controlled ventilation, comparing different equations with the geometric reference method, to understand whether the easier to use surrogate formulas were suitable for the everyday clinical practice. This would warrant a more widespread use of mechanical power to promote lung protection. Methods Forty respiratory failure patients, sedated and paralyzed for clinical reasons, were ventilated in volume-controlled ventilation, at two inspiratory flows (30 and 60 L/min), and pressure-controlled ventilation with a similar tidal volume. Mechanical power was computed both with the geometric method, as the area between the inspiratory limb of the airway pressure and the volume, and with two algebraic methods, a comprehensive and a surrogate formula. Results The bias between the MP computed by the geometric method and by the comprehensive algebraic method during volume-controlled ventilation was respectively 0.053 (0.77, − 0.81) J/min and − 0.4 (0.70, − 1.50) J/min at low and high flows ( r 2  = 0.96 and 0.97, p  < 0.01). The MP measured and computed by the two methods were highly correlated ( r 2  = 0.95 and 0.94, p  < 0.01) with a bias of − 0.0074 (0.91, − 0.93) and − 1.0 (0.45, − 2.52) J/min at high-low flows. During pressure-controlled ventilation, the bias between the MP measured and the one calculated with the comprehensive and simplified methods was correlated ( r 2  = 0.81, 0.94, p  < 0.01) with mean differences of − 0.001 (2.05, − 2.05) and − 0.81 (2.11, − 0.48) J/min. Conclusions Both for volume-controlled and pressure-controlled ventilation, the surrogate formulas approximate the reference method well enough to warrant their use in the everyday clinical practice. Given that these formulas require nothing more than the variables already displayed by the intensive care ventilator, a more widespread use of mechanical power should be encouraged to promote lung protection against ventilator-induced lung injury.

To assess whether, in a lung resection cohort with a low probability of confounding by indication, higher FiO2 is associated with an increased risk of impaired postoperative oxygenation – a clinical manifestation of lung injury/dysfunction. Pre-specified registry-based retrospective cohort study. Two large academic hospitals in the United States. 2936 lung resection patients with an overall good intraoperative oxygenation (median intraoperative SpO2 ≥ 95 %). We compared patients with a higher (≥0.8) and lower (<0.8) median intraoperative FiO2 after propensity score-weighting for 75 perioperative variables based on a causal inference framework. The primary outcome of impaired oxygenation was defined as at least one of the following within seven postoperative days: (1) SpO2 < 92 %; (2) imputed PaO2/FiO2 < 300 mmHg [(1) or (2) at least twice within 24 h]; (3) intensive oxygen therapy (mechanical ventilation or > 50 % oxygen or high-flow oxygen). Among the 2936 included patients, 2171 (73.8 %) received median intraoperative FiO2 ≥ 0.8. Impaired postoperative oxygenation occurred in 1627 (74.9 %) and 422 (55.2 %) patients in the higher and lower FiO2 groups, respectively. In a propensity score-weighted analysis, higher intraoperative FiO2 was associated with an 84 % increase in the likelihood of impaired postoperative oxygenation (OR 1.84; 95 % CI 1.60 to 2.12; P < 0.001). Despite plausible harm from hyperoxia, high intraoperative FiO2 is extremely common during lung resection. Nearly three-quarters of lung resection patients with acceptable oxygenation received median intraoperative FiO2 ≥ 0.8. Such higher FiO2 was associated with an increased risk of impaired postoperative oxygenation – a clinically relevant manifestation of lung injury or dysfunction. This observation supports the administration of a lower (< 0.8) intraoperative FiO2 and its further assessment in clinical trials. •FiO2 as a component of protective ventilation received minimal attention in lung resection•We assessed the effects of intraoperative FiO2 on postoperative oxygenation in lung resection patients•To address confounding by indication, we studied only patients who had an overall good intraoperative oxygenation•After adjusting for over 70 variables, higher intraoperative FiO2 was associated with worse postoperative oxygenation

Background Acute respiratory distress syndrome is characterized by damage to the lung caused by various insults, including ventilation itself, and tidal hyperinflation can lead to ventilator induced lung injury (VILI). We investigated the effects of a low tidal volume ( V T ) strategy ( V T  ≈ 3 ml/kg/predicted body weight [PBW]) using pumpless extracorporeal lung assist in established ARDS. Methods Seventy-nine patients were enrolled after a ‘stabilization period’ (24 h with optimized therapy and high PEEP). They were randomly assigned to receive a low V T ventilation (≈3 ml/kg) combined with extracorporeal CO 2 elimination, or to a ARDSNet strategy (≈6 ml/kg) without the extracorporeal device. The primary outcome was the 28-days and 60-days ventilator-free days (VFD). Secondary outcome parameters were respiratory mechanics, gas exchange, analgesic/sedation use, complications and hospital mortality. Results Ventilation with very low V T ’s was easy to implement with extracorporeal CO 2 -removal. VFD’s within 60 days were not different between the study group (33.2 ± 20) and the control group (29.2 ± 21, p  = 0.469), but in more hypoxemic patients (PaO 2 /FIO 2 ≤150) a post hoc analysis demonstrated significant improved VFD-60 in study patients (40.9 ± 12.8) compared to control (28.2 ± 16.4, p  = 0.033). The mortality rate was low (16.5 %) and did not differ between groups. Conclusions The use of very low V T combined with extracorporeal CO 2 removal has the potential to further reduce VILI compared with a ‘normal’ lung protective management. Whether this strategy will improve survival in ARDS patients remains to be determined (Clinical trials NCT 00538928).