Ventilator-associated lung injury
- Robert C Hyzy, MD
Robert C Hyzy, MD
- Professor of Medicine
- University of Michigan Medical Center
An acute lung injury that develops during mechanical ventilation is termed ventilator-induced lung injury (VILI) if it can be proven that the mechanical ventilation caused the acute lung injury. In contrast, ventilator-associated lung injury (VALI) exists if a causative relationship cannot be proven. VALI is the appropriate term in most clinical situations because it is virtually impossible to prove causation outside of the research laboratory .
The pathogenesis, risk factors, incidence, prevention, clinical presentation, diagnosis, and management of VALI are discussed in this topic review. Other complications of mechanical ventilation are described separately. (See "Physiologic and pathophysiologic consequences of mechanical ventilation" and "Diagnosis, management, and prevention of pulmonary barotrauma during invasive mechanical ventilation in adults".)
Alveolar overdistension and cyclic atelectasis are the principal initiators of alveolar injury during positive pressure ventilation . Severe alveolar injury results in high permeability interstitial and alveolar edema, alveolar hemorrhage, hyaline membranes, loss of functional surfactant, and alveolar collapse [1,3]. The relative importance of alveolar overdistension and cyclic atelectasis on the pathogenesis of VALI is unknown .
Alveolar overdistension — Lung injury due to alveolar distension is referred to as alveolar strain. It reflects the presence of an elevated transpulmonary pressure (the difference between the airway pressure and the pleural pressure) or, more broadly, the ratio between the volume of gas delivered during a tidal breath and the amount of aerated lung receiving it . The following animal studies distinguish between the effect of volume and pressure on the lung. Specifically, they demonstrate that high tidal volumes cause lung injury, but high airway pressure does not:
●Rats were mechanically ventilated using high pressure plus high tidal volumes, low pressure plus high tidal volumes, or high pressure plus low tidal volumes . The only group that did not develop lung injury was the group ventilated with low tidal volumes (figure 1).
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