Mechanical Ventilation for Extracorporeal Support

Ventilator-Associated
Lung Injury
Jassmine Bradley RRT-NPS
Department of Respiratory Care / ECMO
Boston Children’s Hospital
Mechanical Ventilation for Extracorporeal Support

Ventilator Associated Lung Injury

Objectives

• Define Ventilator-Associated Lung Injury (VALI).

• Describe mechanisms of injury.
• List and discuss complications of injury.
• Discuss lung-protective ventilation strategies.
Mechanical Ventilation for Extracorporeal Support

Ventilator Associated Lung Injury

Definition

• VALI is defined as an acute lung injury affecting the airways and

parenchyma that is associated with or exacerbated by
mechanical ventilation
• VILI (ventilator-induced lung injury) is when the mechanical
ventilation is the proven cause of injury.

Guerin C, Debord S, Leray V, et al. Efficacy and safety of recruitment maneuvers in acute respiratory distress
syndrome. Ann Intensive Care. 2011;1(1):9. Published 2011 Apr 19. doi:10.1186/2110-5820-1-9
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Ventilator Associated Lung Injury

Mechanisms of Lung Injury

• Pressure or Volume induced lung injuries are most commonly

identified.
o Barotrauma
o Volutrauma
• Others may include:
o Atelectrauma
o Shearing Injury
o Oxygen Toxicity
o Biotrauma
Mechanical Ventilation for Extracorporeal Support

Ventilator Associated Lung Injury

Mechanism: Barotrauma
• Ventilator associated injury caused by high alveolar pressures
that subsequently rupture alveoli causing air to escape the lung
parenchyma and accumulate in the pleural space or other
compartments within the thorax.
• Injuries include
o Pneumothorax
o Pneumomediastinum
o Pnemopericardium
o Subcutaneous emphysema
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Ventilator Associated Lung Injury

Mechanism: Volutrauma

• Lung parenchyma damage caused by alveolar overdistention.

o Increases alveolar permeability leading to pulmonary edema
o ↑compliance = ↑risk for overdistention
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Ventilator Associated Lung Injury

Mechanism: Atelectrauma

• Repetitive recruitment and

derecruitment of the alveoli
during each ventilatory cycle.
• The method used to determine
the amount of PEEP in ARDS
that prevents de-recruitment in
a given alveolar unit is
controversial. However, the
optimal PEEP level prevents
de-recruitment at end
exhalation.
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Ventilator Associated Lung Injury

Mechanism: Shearing Injury

• High inspiratory flow rate and high

respiratory rate result in high shear
forces within lung parenchyma
o Surfactant production decreases
o Epithelial cell damage increases
o Alveolar surface tension and capillary
permeability increases
 Ultimately results in pulmonary
edema
(A) Homogeneous alveolar inflation minimizes strain. (B) Atelectasis of center
alveolus induces shear strain of neighboring alveoli. (C) Asymmetric inflation
of center alveolus induces shear strain of neighboring alveoli. (D) CT chest
with overlying map of CT-derived regional stress concentration due to
parenchymal heterogeneity in a representative patient with ARDS (light blue:
low stress; orange: moderate stress; red: high stress).

• Wang, et al. Effects of dynamic ventilatory factors on ventilator-induced lung injury in acute respiratory
distress syndrome dogs. World J Emerg Med 2012; 3(4): 287–293.
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Ventilator Associated Lung Injury

Mechanism: Oxygen Toxicity

Hyperoxia that leads to oxygen poisoning

o Pulmonary fibrosis
o Bronchopulmonary dysplasia
o Retinopathy of prematurity

• Freeman BA, Crapo JD. Hyperoxia increases oxygen radical production in rat lungs and lung
mitochondria. J Biol Chem 1981; 256:10986.

• Winslow RM. Oxygen: the poison is in the dose. Transfusion 2013; 53:424.
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Ventilator Associated Lung Injury

Mechanism: Oxygen Toxicity

• Absorption atelectasis
o High volume of nitrogen that is washed out by increased FiO2 resulting in
alveolar collapse.
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Ventilator Associated Lung Injury

Mechanism: Biotrauma

• Pulmonary and systemic

inflammation caused by
overdistention and repetitive
opening and closing of alveoli
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Ventilator Associated Lung Injury

Acute Respiratory Distress Syndrome (ARDS)

• An acute lung injury characterized by hypoxia,

pulmonary edema and alveolar collapse
o Berlin definition of onset if within one week of known
clinical insult or new/worsening respiratory
symptoms
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Ventilator Associated Lung Injury

Acute Respiratory Distress Syndrome (ARDS)

• Radiological findings
o Bilateral opacities not explained by effusions, lung collapse,
or nodules
• Degree of hypoxemia with PEEP ≥5 cmH2O
o Mild ARDS: PaO2/FiO2 ≤ 300
o Moderate ARDS: PaO2/FiO2 ≤ 200
o Severe ARDS: PaO2/FiO2 ≤ 100
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Ventilator Associated Lung Injury

Acute Respiratory Distress Syndrome (ARDS)
Oxygen Index (OI)
• Calculation used to estimate the severity of hypoxemia
o OI = (PawXFiO2)/ PaO2 x 100
• Degree of hypoxemia
o Mild ARDS: 4-8
o Moderate ARDS: 8-16
o Severe ARDS: > 16
Oxygen Saturation Index (OSI)
• Substitution used for OI in patients lacking arterial
access
o OI = (PawXFiO2)/ SpO2 x 100
• Degree of hypoxemia
o Mild ARDS: 5-7.5
o Moderate ARDS: 7.5-12.3
o Severe ARDS: > 12.3
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Ventilator Associated Lung Injury

Lung-Protective Ventilation Strategies

• Low tidal volumes and respiratory

rates
• Permissive hypercapnea
• Prone positioning
• High frequency ventilation
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Ventilator Associated Lung Injury

Low tidal volumes and respiratory rates

•Limit tidal volumes to avoid overdistention

o4-6 mL/kg IBW

•Limit respiratory rate to reduce stress frequency

o<6 mos: 20-60 breaths/min
o6mos-2 yo: 15-45 breaths/min
o2-5 yo: 15/40 breaths/min
o>5 yo: 10-35 breaths /min
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Ventilator Associated Lung Injury

Plateau Pressure

• Often seen as Pplat, is measured by an inspiratory

hold maneuver
• To avoid injury, it is recommended to maintain ≤ 30
cmH2O
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Ventilator Associated Lung Injury

Driving Pressure

• Expressed as Pplat – PEEP

• Targeting pressures ≤ 15 cmH2O significantly
reduces mortality in patients with ARDS
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Ventilator Associated Lung Injury

Permissive Hypercapnea

• Controlled hypoventilation by accepting higher

PaCO2 values in patients with ARDS
• Permits lung protective ventilation with low Vt
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Ventilator Associated Lung Injury

Prone Positioning
• Mainly used in
patients with
severe
hypoxemia with
ARDS
• Alters mechanics
and physiology of
gas exchange
• Improves lung
perfusion
• Reduces dorsal
lung compliance
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Ventilator Associated Lung Injury

High Frequency Ventilation

HFV is a form of mechanical ventilation that

combines very high respiratory rates (>60
breaths per minute) with tidal volumes that are
smaller than the volume of anatomic dead space

• High Frequency Oscillatory Ventilation

• High Frequency Jet Ventilation
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Ventilator Associated Lung Injury

High Frequency Oscillatory Ventilation (HFOV)

• HFOV is a rescue lung-protective strategy that is

utilized when CMV has failed.
o Provides constant Paw to maintain alveolar
recruitment
o Utilizes volumes that are less than dead space
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Ventilator Associated Lung Injury

High Frequency Jet Ventilation (HFJV)

• HFJV is used to minimize lung trauma through ultra-

low Vt ventilation at optimal lung recruitment
o High velocity Vt minimizes the effect of dead space
o Paw is generated from CMV via PEEP
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Ventilator Associated Lung Injury

Conclusion

VILI occurs from barotrauma, volutrauma,

atelectrauma, O2 toxicity, and biotrauma.
Interventions to mitigate these mechanisms of injury
are readily available to protects against VILI.
Prevention of VALI/VILI can reduce effects of
multiorgan failure and ARDS and improves survival of
at-risk patients.
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Ventilator Associated Lung Injury

Questions?
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Ventilator Associated Lung Injury

Thank You!
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Ventilator Associated Lung Injury

References
• Beitler, J. R., Malhotra, A., & Thompson, B. T. (2016). Ventilator-Induced Lung Injury. HHS Author
Manuscripts. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5131805/.
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Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. The New
England Journal of Medicine, 378(21).
• Freeman BA, Crapo JD. (1981). Hyperoxia Increases Oxygen Radical Production in Rat Lungs and
Lung Mitochondria. J Biol Chem; 256(10986).
• Hess, D., Kacmarek, R. M. (2019). Essentials of Mechanical Ventilation. New York: McGraw-Hill
Education.
• Hess, D., MacIntyre, N. R., Mishoe, S. C., Galvin, W. F., & Adams, A. B. (2012). Respiratory
Care: Principles and Practice. Sudbury, MA: Jones & Bartlett Learning.
• Prabhakaran, P., Sasser, W. C., Kalra, Y., Rutledge, C., & Tofil, N. M. (2016). Ventilator Graphics.
Minerva Pediatrica.
• Respiratory Care Manual. (2014). PARDS Lung Protective Ventilation. Boston Children's Hospital.
• Walsh, B. K. (2015). Neonatal and Pediatric Respiratory Care. St. Louis: Elsevier/Saunders.
• Winslow RM. (2013). Oxygen: The Poison is in the Dose. Transfusion, 53(424).