VENTILATOR INDUCED LUNG INJURY VILI - DR MIGUEL IBARRA -CASTRADA ( MEXICO )

Food for thought 🤠🙋‍♂️🙋‍♀️
Is overdistension or atelectasis more harmful ?

Summary
DR Miguel Ibarra

Low Tidal Volume in Protective Ventilation
Miguel highlighted the importance of low tidal volume in protective ventilation, noting that a significant number of patients were not receiving the recommended volume. He cited a real-life example from a Mexican intensive care unit where a patient was receiving excessively high tidal volumes, putting undue strain on their lungs. Miguel emphasized that the benefit of low tidal volume is only observable when compared to much higher volumes, and called for a more nuanced approach to ventilation strategies, rather than a one-size-fits-all approach.
Personalized Ventilation Strategies for ARDS
Miguel emphasized that not all patients with a diagnosis of ARDS suffer equally and that a one-size-fits-all approach to ventilation may not be optimal. He presented evidence showing that a more protective ventilation strategy, characterized by lower plateau pressures and tidal volumes, can significantly reduce the incidence of ventilator-induced lung injury and mortality. Miguel highlighted the need for personalized ventilation strategies tailored to each patient and stressed the importance of maintaining the lowest possible plateau pressure to minimize inflammation and metabolic activity.
Lung Ventilation Strategies and Physiology
Miguel discussed the complexities of lung ventilation strategies, emphasizing that a one-size-fits-all approach is not ideal. He suggested that the most important factor in lung protection is not the tidal volume per se, but the stress and strain on the alveoli. He stressed the importance of considering the patient's functional residual capacity and compliance when determining the appropriate tidal volume. Miguel also highlighted the significance of the driving pressure as a strong physiological rationale for lung ventilation strategies.
Mechanical Ventilation and Tidal Volume Management
Miguel discussed the complex relationship between driving pressure, plateau pressure, and tidal volume in the context of mechanical ventilation. He emphasized that increasing tidal volume could lead to a proportional increase in plateau pressure, which in turn raises the risk of mortality. However, he also noted that increasing tidal volume could improve oxygenation and recruit more units without inducing excessive lung injury. Miguel stressed the importance of maintaining a safe level of plateau pressure and warned against increasing tidal volume excessively, as this could lead to overdistension. He presented two options to manage this situation: reducing tidal volume or reducing the peep.
Optimizing Lung Recruitment and Ventilation Strategies
Miguel discussed various strategies for optimizing lung recruitment and ventilation in patients. He highlighted the promising results of a study by Ahmad and Amato, emphasizing the importance of personalizing tidal volumes based on the stress index. Miguel also introduced the concept of 'recruitment to inflation radio', which is a calculation that compares the compliance of newly recruited patients with that of previously open patients to determine potential responses to increasing PIP. He stressed that no single strategy fits all patients and encouraged a tailored approach. Miguel also mentioned ongoing studies testing these strategies and their potential benefits.
Manipulating Driving Pressure and Lung Compliance
Miguel presented an in-depth discussion on the manipulation of the equation of driving pressure, the importance of lung compliance, and the dangers of over-inflation. He emphasized the need to monitor lung inflation in real time and the potential negative effects of increasing any variable without decreasing another. Miguel also touched on the topic of patient-induced lung injury and the importance of avoiding it, highlighting the time-sensitive nature of this issue. He stressed the three circumstances in which lung damage can occur: by the mechanical ventilation, the patient's own efforts, and external factors. The presentation concluded with Miguel pointing out the driving pressure as a promising strategy in all these circumstances.
Comparative Ventilation Modes and Challenges

00:00:00 intro
00:02:40 what is vili
00:04:40 barotrauma
00:06:48 volutrauma
00:08:49 atelectetrauma
00:10:00 biotrauma
00:10:11 tidal volume
00:19:41 one size does not fit all
00:31:10 DP
00:38:36 DP and Pplat
00:39:19 best peep
00:47:23 asynchrony, reverse triggering
00:52:05 discussion