Ventilatory support and mechanical properties of the fibrotic lung acting as a “squishy ball”
Alessandro Marchioni, Roberto Tonelli, Giulio Rossi, Paolo Spagnolo, Fabrizio Luppi, Stefania Cerri, Elisabetta Cocconcelli, Maria Rosaria Pellegrino, Riccardo Fantini, Luca Tabbì, Ivana Castaniere, Lorenzo Ball, Manu L. N. G. Malbrain, Paolo Pelosi, Enrico Clini
Abstract
Protective ventilation is the cornerstone of treatment of patients with the acute respiratory distress syndrome (ARDS); however, no studies have yet established the best ventilatory strategy to adopt when patients with acute exacerbation of interstitial lung disease (AE-ILD) are admitted to the intensive care unit. Due to the severe impairment of the respiratory mechanics, the fibrotic lung is at high risk of developing ventilator-induced lung injury, regardless of the lung fibrosis etiology. The purpose of this review is to analyze the effects of mechanical ventilation in AE-ILD and to increase the knowledge on the characteristics of fibrotic lung during artificial ventilation, introducing the concept of "squishy ball lung". The role of positive end-expiratory pressure is discussed, proposing a "lung resting strategy" as opposed to the "open lung approach". The review also discusses the practical management of AE-ILD patients discussing illustrative clinical cases.