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Diagnosis, management, and prevention of pulmonary barotrauma during invasive mechanical ventilation in adults

Robert C Hyzy, MD
Section Editor
Polly E Parsons, MD
Deputy Editor
Geraldine Finlay, MD


Pulmonary barotrauma can complicate mechanical ventilation. It is most often due to alveolar rupture resulting in the release of air into extra-alveolar locations [1]. Pulmonary barotrauma may be associated with increased mortality and in some circumstances it may be life-threatening. Thus, it is important that clinicians prevent, recognize, and promptly manage barotrauma in this population.

The prevention, diagnostic evaluation, and management of pulmonary barotrauma are discussed in this topic review. Additional complications of mechanical ventilation are described separately. (See "Physiologic and pathophysiologic consequences of mechanical ventilation".)


Barotrauma is physical damage to body tissues caused by a difference in pressure between a gas space inside the body and its surrounding external environment. Pulmonary barotrauma from invasive mechanical ventilation refers to alveolar rupture due to elevated transalveolar pressure (the alveolar pressure minus the pressure in the adjacent interstitial space); air leaks into extra-alveolar tissue resulting in conditions including pneumothorax, pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema. (See 'Alveolar rupture' below and 'Diagnostic evaluation and management' below.)  

Although not true barotrauma, direct injury to the alveolar or pleural space (eg, from chest trauma or biopsy) results in conditions that present and are managed similarly. Thus, they will be included in this topic for the purposes of discussion. (See 'Direct injury' below.)


The incidence of barotrauma during mechanical ventilation varies with the underlying indication for mechanical ventilation but ranges from 0 to 50 percent [2-7]. Since the application of low tidal volume ventilation in the mid-2000s, the rate may now be on the lower end of this range (approximately 10 percent or less).


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Literature review current through: Sep 2016. | This topic last updated: Jul 19, 2016.
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  1. Doelken P, Sahn SA. Pleural disease in the critically ill patient. In: Intensive Care Medicine, 6th ed, Irwin RS, Rippe JM (Eds), Lippincott, Williams, and Wilkins, Philadelphia 2008. p.636.
  2. Anzueto A, Frutos-Vivar F, Esteban A, et al. Incidence, risk factors and outcome of barotrauma in mechanically ventilated patients. Intensive Care Med 2004; 30:612.
  3. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000; 342:1301.
  4. Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 2004; 351:327.
  5. Boussarsar M, Thierry G, Jaber S, et al. Relationship between ventilatory settings and barotrauma in the acute respiratory distress syndrome. Intensive Care Med 2002; 28:406.
  6. Petersen GW, Baier H. Incidence of pulmonary barotrauma in a medical ICU. Crit Care Med 1983; 11:67.
  7. Torosyan Y, Hu Y, Hoffman S, et al. An in silico framework for integrating epidemiologic and genetic evidence with health care applications: ventilation-related pneumothorax as a case illustration. J Am Med Inform Assoc 2016; 23:711.
  8. Parker JC, Hernandez LA, Peevy KJ. Mechanisms of ventilator-induced lung injury. Crit Care Med 1993; 21:131.
  9. Pingleton SK. Barotrauma in acute lung injury: is it important? Crit Care Med 1995; 23:223.
  10. Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med 1984; 144:1447.
  11. Fukushima K, Marut K, Kiyofuji C, Sugimoto M. [Evaluation of the incidence of pneumothorax and background of patients with pneumothorax during noninvasive positive pressure ventilation]. Nihon Kokyuki Gakkai Zasshi 2008; 46:870.
  12. Carron M, Gagliardi G, Michielan F, et al. Occurrence of pneumothorax during noninvasive positive pressure ventilation through a helmet. J Clin Anesth 2007; 19:632.
  13. Rocha E, Carneiro EM. Benefits and complications of noninvasive mechanical ventilation for acute exacerbation of chronic obstructive pulmonary disease. Rev Bras Ter Intensiva 2008; 20:184.
  14. Vianello A, Arcaro G, Gallan F, et al. Pneumothorax associated with long-term non-invasive positive pressure ventilation in Duchenne muscular dystrophy. Neuromuscul Disord 2004; 14:353.
  15. Simonds AK. Pneumothorax: an important complication of non-invasive ventilation in neuromuscular disease. Neuromuscul Disord 2004; 14:351.
  16. International consensus conferences in intensive care medicine: Ventilator-associated Lung Injury in ARDS. This official conference report was cosponsored by the American Thoracic Society, The European Society of Intensive Care Medicine, and The Societé de Réanimation de Langue Française, and was approved by the ATS Board of Directors, July 1999. Am J Respir Crit Care Med 1999; 160:2118.
  17. Tuxen DV, Lane S. The effects of ventilatory pattern on hyperinflation, airway pressures, and circulation in mechanical ventilation of patients with severe air-flow obstruction. Am Rev Respir Dis 1987; 136:872.
  18. Manning HL. Peak airway pressure: why the fuss? Chest 1994; 105:242.
  19. Marini JJ, Ravenscraft SA. Mean airway pressure: physiologic determinants and clinical importance--Part 2: Clinical implications. Crit Care Med 1992; 20:1604.
  20. Williams TJ, Tuxen DV, Scheinkestel CD, et al. Risk factors for morbidity in mechanically ventilated patients with acute severe asthma. Am Rev Respir Dis 1992; 146:607.
  21. Weg JG, Anzueto A, Balk RA, et al. The relation of pneumothorax and other air leaks to mortality in the acute respiratory distress syndrome. N Engl J Med 1998; 338:341.
  22. Eisner MD, Thompson BT, Schoenfeld D, et al. Airway pressures and early barotrauma in patients with acute lung injury and acute respiratory distress syndrome. Am J Respir Crit Care Med 2002; 165:978.
  23. Schnapp LM, Chin DP, Szaflarski N, Matthay MA. Frequency and importance of barotrauma in 100 patients with acute lung injury. Crit Care Med 1995; 23:272.
  24. Hodgson C, Keating JL, Holland AE, et al. Recruitment manoeuvres for adults with acute lung injury receiving mechanical ventilation. Cochrane Database Syst Rev 2009; :CD006667.
  25. Briel M, Meade M, Mercat A, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA 2010; 303:865.
  26. Mercat A, Richard JC, Vielle B, et al. Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2008; 299:646.
  27. Meade MO, Cook DJ, Guyatt GH, et al. Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2008; 299:637.
  28. Santa Cruz R, Rojas JI, Nervi R, et al. High versus low positive end-expiratory pressure (PEEP) levels for mechanically ventilated adult patients with acute lung injury and acute respiratory distress syndrome. Cochrane Database Syst Rev 2013; :CD009098.
  29. Kacmarek RM, Villar J, Sulemanji D, et al. Open Lung Approach for the Acute Respiratory Distress Syndrome: A Pilot, Randomized Controlled Trial. Crit Care Med 2016; 44:32.
  30. Suzumura EA, Figueiró M, Normilio-Silva K, et al. Effects of alveolar recruitment maneuvers on clinical outcomes in patients with acute respiratory distress syndrome: a systematic review and meta-analysis. Intensive Care Med 2014; 40:1227.
  31. Chacko B, Peter JV, Tharyan P, et al. Pressure-controlled versus volume-controlled ventilation for acute respiratory failure due to acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). Cochrane Database Syst Rev 2015; 1:CD008807.
  32. Burns KE, Adhikari NK, Slutsky AS, et al. Pressure and volume limited ventilation for the ventilatory management of patients with acute lung injury: a systematic review and meta-analysis. PLoS One 2011; 6:e14623.
  33. Gammon RB, Shin MS, Groves RH Jr, et al. Clinical risk factors for pulmonary barotrauma: a multivariate analysis. Am J Respir Crit Care Med 1995; 152:1235.
  34. Amato MB, Barbas CS, Medeiros DM, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 1998; 338:347.
  35. Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 2010; 363:1107.
  36. Alhazzani W, Alshahrani M, Jaeschke R, et al. Neuromuscular blocking agents in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials. Crit Care 2013; 17:R43.
  37. Morris WP, Butler BD, Tonnesen AS, Allen SJ. Continuous venous air embolism in patients receiving positive end-expiratory pressure. Am Rev Respir Dis 1993; 147:1034.
  38. Rankine JJ, Thomas AN, Fluechter D. Diagnosis of pneumothorax in critically ill adults. Postgrad Med J 2000; 76:399.
  39. Vezzani A, Brusasco C, Palermo S, et al. Ultrasound localization of central vein catheter and detection of postprocedural pneumothorax: an alternative to chest radiography. Crit Care Med 2010; 38:533.
  40. Shennib HF, Barkun AN, Matouk E, Blundell PE. Surgical decompression of a tension pneumomediastinum. A ventilatory complication of status asthmaticus. Chest 1988; 93:1301.
  41. Winer-Muram HT, Rumbak MJ, Bain RS Jr. Tension pneumoperitoneum as a complication of barotrauma. Crit Care Med 1993; 21:941.
  42. Caceres M, Braud RL, Maekawa R, et al. Secondary pneumomediastinum: a retrospective comparative analysis. Lung 2009; 187:341.
  43. Levine MS, Scheiner JD, Rubesin SE, et al. Diagnosis of pneumoperitoneum on supine abdominal radiographs. AJR Am J Roentgenol 1991; 156:731.
  44. DeGorordo A, Vallejo-Manzur F, Chanin K, Varon J. Diving emergencies. Resuscitation 2003; 59:171.
  45. Perraut M, Gilday D, Reed G. Traumatic occurrence of chest wall tamponade secondary to subcutaneous emphysema. CJEM 2008; 10:387.
  46. Sucena M, Coelho F, Almeida T, et al. [Massive subcutaneous emphysema--management using subcutaneous drains]. Rev Port Pneumol 2010; 16:321.
  47. Gries CJ, Pierson DJ. Tracheal rupture resulting in life-threatening subcutaneous emphysema. Respir Care 2007; 52:191.
  48. Son BS, Lee S, Cho WH, et al. Modified blowhole skin incision using negative pressure wound therapy in the treatment of ventilator-related severe subcutaneous emphysema. Interact Cardiovasc Thorac Surg 2014; 19:904.
  49. O'Reilly P, Chen HK, Wiseman R. Management of extensive subcutaneous emphysema with a subcutaneous drain. Respirol Case Rep 2013; 1:28.
  50. Barcia SM, Kukreja J, Jones KD. Pulmonary interstitial emphysema in adults: a clinicopathologic study of 53 lung explants. Am J Surg Pathol 2014; 38:339.
  51. Pierson DJ, Horton CA, Bates PW. Persistent bronchopleural air leak during mechanical ventilation. A review of 39 cases. Chest 1986; 90:321.
  52. Gattinoni L, Bombino M, Pelosi P, et al. Lung structure and function in different stages of severe adult respiratory distress syndrome. JAMA 1994; 271:1772.