“Less is More” in mechanical ventilation

Abstract

Though formed in the late 1960s, the field of intensive care medicine solidified its place in the 1970s.Critical care practitioners were typically young and enthusiastic, but lacked the benefit of guidance from an established scientific literature or the experience of "older mentors, " as simply they did not exist.The rational basis of this new specialty was systems physiology and short-term observation, on which most of its monitoring and interventions are based.Interestingly, not only were the "intensivists" young, but so were the patients, compared to now.Very importantly, we naively assumed uniformity of diseases and disease mechanisms and translated our familiar deep knowledge of normal physiology to the pathologic state.Energy, enthusiasm and the pioneering attitudes of the young intensivists were associated with a widespread tendency to "exceed" the confines of prior experience.Adverse consequences gradually became evident.This exuberance characterized many elements of practice: in septic patients, if milligrams of corticosteroids are good, grams might be better [1].In nutrition, if 2000 kcal/day is good, 5000 must be better [2].The same applies to sedations and fluids administration.In hemodynamics, supranormal values of oxygen transport must be better [3], etc. Essentially, the intensivists of that era were doing the same things as we are now, but with far greater dosage, extent and intensity.ARDS is one of the best examples of our evolution from "more-to-less, " nurtured by the difficult lessons of our experience (Fig. 1).

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