Diagnosis, management, and prevention of pulmonary barotrauma during invasive mechanical ventilation in adults
- Robert C Hyzy, MD
Robert C Hyzy, MD
- Professor of Medicine
- University of Michigan Medical Center
Pulmonary barotrauma can complicate mechanical ventilation. It is most often due to alveolar rupture resulting in the release of air into extra-alveolar locations . 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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- PATHOGENESIS AND RISK FACTORS
- Alveolar rupture
- - Ventilator-related
- Positive pressure ventilation
- Elevated pressures
- - Disease-related
- Direct injury
- Low plateau pressure
- Low tidal volume ventilation
- Avoidance or treatment of dynamic hyperinflation
- Other strategies
- DIAGNOSTIC EVALUATION AND MANAGEMENT
- Barotrauma diagnosis and management
- - Pneumothorax
- - Pneumomediastinum
- - Pneumoperitoneum
- - Subcutaneous emphysema
- - Others
- Ventilator management
- Management of underlying disorder
- SUMMARY AND RECOMMENDATIONS