This effect is achieved by taking over the function of patients’ respiratory muscles ( 2). In fact, mechanical ventilation per se is not a cure for ARDS it works by simply buying time by maintaining a sufficient gas exchange for patient survival. Despite extensive research over nearly half a century, no specific therapy exists for ARDS, and mechanical ventilation remains the key form of supportive care ( 1). The wide majority of critically ill patients are subject to invasive mechanical ventilation during their stay in the intensive care unit, and patients with acute respiratory distress syndrome (ARDS) are almost invariably managed by invasive mechanical ventilation. Eventually, the role of other ventilator-related parameters in the generation of VILI will be considered (namely, plateau pressure, airway driving pressure, respiratory rate (RR), inspiratory flow), and the promising unifying framework of mechanical power will be presented. An ultra-low tidal volume strategy with the use of extracorporeal carbon dioxide removal (ECCO 2R) will be presented and discussed. The still actual suggestion of a lung-protective ventilatory strategy based on the use of low tidal volumes scaled to the predicted body weight (PBW) will be presented, together with newer strategies such as the use of airway driving pressure as a surrogate for the amount of ventilatable lung tissue or the concept of strain, i.e., the ratio between the tidal volume delivered relative to the resting condition, that is the functional residual capacity (FRC). The relationship between tidal volume and the development of VILI, the so called volotrauma, will be reviewed. The present paper illustrates the physiological effects of delivering a tidal volume to the lungs of patients with ARDS, and suggests an approach to tidal volume selection. Experimental evidence accumulated over the last 30 years highlighted the factors associated with an injurious form of mechanical ventilation. Moreover, it can further damage the lung, leading to the development of a particular form of lung injury named ventilator-induced lung injury (VILI). However, this form of support does not constitute a cure for acute respiratory distress syndrome (ARDS), as it mainly works by buying time for the lungs to heal while contributing to the maintenance of vital gas exchange. Mechanical ventilation is the type of organ support most widely provided in the intensive care unit.
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