Patient-Self Inflicted Lung Injury: A Practical Review

Patients with severe lung injury usually have a high respiratory drive, resulting in intense inspiratory effort that may even worsen lung damage by several mechanisms gathered under the name patient-self inflicted lung injury (P-SILI). Even though no clinical study has yet demonstrated that a ventilatory strategy to limit the risk of P-SILI can improve the outcome, the concept of P-SILI relies on sound physiological reasoning, an accumulation of clinical observations and some consistent experimental data. In this review, we detail the main pathophysiological mechanisms by which the patient's respiratory effort could become deleterious: excessive transpulmonary pressure resulting in over-distension; inhomogeneous distribution of transpulmonary pressure variations across the lung leading to cyclic opening/closing of nondependent regions and pendelluft phenomenon; increase in the transvascular pressure favoring the aggravation of pulmonary edema. We also describe potentially harmful patient-ventilator interactions. Finally, we discuss in a practical way how to detect in the clinical setting situations at risk for P-SILI and to what extent this recognition can help personalize the treatment strategy.

Automated summary

This review details the main pathophysiological mechanisms by which the patient's respiratory effort could become deleterious, including excessive over-distension, inhomogeneous distribution of pressure variations across the lung, and increase in transvascular pressure leading to aggravated pulmonary edema. Harmful patient-ventilator interactions are also discussed, along with practical ways to detect situations at risk for P-SILI in clinical settings and personalize treatment strategies.