Background Patient-ventilator interaction (PVI) emerges from the continuous interaction between physiological signals generated by the patient and signals generated, measured, or displayed by the mechanical ventilator. Traditionally, PVI has been described predominantly through recognizable forms of patient-ventilator asynchrony. Although this approach remains clinically useful, the visible waveform abnormalities represent the final expression of interactions occurring between multiple neural, muscular, mechanical and ventilator signals. Methods This conceptual narrative review builds on contemporary PVI taxonomies by organizing bedside analysis around the relationships between selected patient and ventilator signals. Patient-derived physiological signals may reflect neural respiratory activity, respiratory muscle activation, and respiratory muscle pressure, whereas ventilator-derived signals include mechanical breath onset, assistance delivery, cycling-off, and ventilator-measured airway pressure, flow and volume. Rather than introducing new PVI categories, the framework uses four sequential relational questions: whether expected patient and ventilator signals correspond; whether their inspiratory onsets are appropriately aligned; whether their inspiratory offsets are appropriately aligned; and whether the magnitude of ventilator-delivered assistance is appropriate for the intended physiological target. Loss of expected correspondence produces abnormalities such as failed triggering and unintended (false) triggering. Abnormal temporal relationships between corresponding inspiratory onsets produce early or late triggering, whereas abnormal offset relationships produce early or late cycling. Appropriate timing, however, does not guarantee appropriate assistance: under-assistance and over-assistance represent abnormalities in the magnitude of ventilator contribution relative to patient respiratory demand and the intended unloading goal. The same signal-identification approach is applied across the expiratory phase, where active expiratory muscle contraction, expiratory-flow deformation, persistence of inspiratory activity after cycling-off, and expiratory muscle relaxation may alter waveform appearance and influence subsequent triggering. Directionality is treated as an interpretive modifier when temporal sequence alone is insufficient to establish the underlying mechanism. Reverse triggering illustrates this distinction, demonstrating that the interaction may proceed from the ventilator to the patient rather than from the patient to the ventilator. Conclusions A stepwise bedside algorithm is proposed to translate this signal-based framework into practical waveform interpretation. Understanding which signals are interacting, how they correspond, how their timing and magnitude relate, and how interactions propagate across respiratory phases provides a physiological path toward more precise interpretation of PVI and ultimately towards optimal patient-ventilator interaction.
Background In patients with amyotrophic lateral sclerosis (ALS) receiving long-term tracheostomy invasive ventilation (TIV), peri-cuff air leakage may be related not only to insufficient cuff pressure but also to tracheal enlargement and cuff–trachea diameter mismatch. However, to our knowledge, no previous studies have compared computed tomography (CT)-derived tracheal dimensions, tracheostomy tube and cuff characteristics, and ventilator monitoring data between patients with and without peri-cuff air leakage under long-term TIV management in ALS. Methods This was a single-center, retrospective, cross-sectional observational study. Patients with ALS who were receiving TIV at the study hospital in October 2020 and had undergone chest CT within the 3 months before patient selection were included. Patients were classified into the leak and non-leak groups according to the presence or absence of peri-cuff air leakage based on medical record entries during the period from 1 month before to 1 month after the index CT examination. Patient characteristics, tracheostomy tube and cuff characteristics, CT-derived tracheal dimensions, and ventilator monitoring data were compared between the groups. Results Twenty-six patients were included in the analysis: 10 in the leak group and 16 in the non-leak group. Patient characteristics did not differ significantly between the groups. Compared with the non-leak group, the leak group had higher cuff pressure, larger major and minor tracheal diameters, higher peak inspiratory pressure, a larger difference between major and minor tracheal diameters, lower dynamic compliance, and a smaller difference between cuff diameter and major tracheal diameter. The difference between cuff diameter and major tracheal diameter was −2.3 (−4.1 to −1.6) mm in the leak group and 1.8 (0.7 to 3.0) mm in the non-leak group (P < 0.001). The Hodges–Lehmann estimate of the between-group difference was −4.7 mm (95% CI, −7.4 to −3.2 mm). All patients in whom the cuff diameter was smaller than the major tracheal diameter were classified into the leak group. Conclusions In patients with ALS receiving long-term TIV, peri-cuff air leakage was associated with larger CT-derived tracheal dimensions and a smaller cuff diameter relative to the major tracheal diameter. These findings suggest that cuff–trachea diameter compatibility, in addition to cuff pressure, may be relevant when evaluating peri-cuff air leakage. However, the small sample size limited statistical precision and precluded multivariable adjustment; therefore, the findings should be interpreted as exploratory.
Background Mechanical power (MP) integrates multiple ventilatory variables into a single measure of the energy delivered to the respiratory system and has been associated with ventilator-induced lung injury and adverse outcomes. However, it remains unclear whether ventilatory observations meeting conventional protective criteria also exhibit low MP and whether small ventilatory adjustments can meaningfully reduce MP in severely burned patients undergoing pressure-controlled ventilation (PCV). Methods This interventional repeated-measures study with randomized sequence of ventilatory adjustment protocols included adult burn patients receiving PCV in an intensive care unit. A total of 123 paired ventilatory observations were screened. Three reductive ventilatory strategies were assessed: reduction of inspiratory pressure variation by 2 cmH2O (ΔPinsp), reduction of respiratory rate by 2 breaths/min (RR), and combined reductions of 1 cmH2O and 1 breath/min (RR–ΔPinsp). Thirty-nine ventilatory observations meeting predefined protective tidal-volume and pressure criteria constituted the analytical sample. MP was calculated using the simplified Becher equation. Clinical, arterial blood gases, and ventilatory effects were evaluated at baseline and one hour after the interventions, as well as migration between MP categories (<1 8 and ≥ 18 J/min). Results Oxygenation remained stable, with no significant changes in PaO2, SpO2, or PaO2/FiO2. PaCO2 increased modestly and arterial pH decreased slightly, but both remained within physiological limits. No desaturation, clinically relevant acidosis, hemodynamic instability, or ventilatory asynchrony was observed. Among the 39 ventilatory observations, 17 (43.6%) had MP ≥ 18 J/min at baseline. MP decreased significantly from 17.39 to 15.02 J/min overall (P < 0.001). The greatest reduction was observed in the ΔPinsp group (3.00 J/min), followed by RR–ΔPinsp (2.34 J/min) and RR (1.78 J/min), with significant differences among strategies. Ventilatory observations with MP <18 J/min increased from 22/39 (56.4%) to 34/39 (87.2%), whereas those with MP ≥ 18 J/min decreased from 17/39 (43.6%) to 5/39 (12.8%) (P < 0.001). Conclusions A substantial proportion of ventilatory observations meeting conventional protective criteria still exhibited elevated MP. Small ventilatory adjustments during protective PCV were associated with significant reductions in calculated MP and migration toward values below 18 J/min without compromising short-term arterial blood gases or clinical stability. Reduction in inspiratory pressure variation produced the greatest effect on MP.
Background Esophageal balloon manometry is a surrogate for pleural pressure and has been in clinical use for decades. The main advantages for its use are to partition the total lung and chest wall mechanics, thus providing transpulmonary inspiratory, expiratory, and driving pressure monitoring as the true stress delivered to the lung, and the capability to measure the transpulmonary mechanical power as the true energy delivered to inflate the lungs. Thus, it is able to provide more insight into lung-protective ventilation than total airway pressure alone. Its capability as the gold standard to measure patient effort, muscle pressure, and to diagnose patient-ventilator interactions and dyssynchronies adds further value to its usage. Proposed Framework As the paradigm shifts toward personalized lung and diaphragm-protective ventilation, alongside increased recognition of ventilator-induced and patient self-inflicted lung injury (VILI and P-SILI respectively), using esophageal balloon manometry seems to be the ultimate tool to achieve these goals. In this paper, we introduce a hypothetical automated closed-loop ventilator mode that is based on adjusting the inspiratory and expiratory transpulmonary pressures to a safe zone to provide true lung-protective ventilation, while simultaneously adjusting the triggering, maintaining, and cycling of breaths according to the patient's neural time and effort, potentially eliminating dyssynchronies. Clinical Implications This adaptive mode aims to optimize the balance between lung recruitment, overdistension, and respiratory muscle unloading, addressing VILI, P-SILI and ventilator-induced diaphragm dysfunction (VIDD). Conclusion A new closed-loop ventilator mode based on continuous input and feedback from the esophageal balloon can conceptually lead to safer personalized ventilation, significantly lessen dyssynchronies, and potentially improve mortality outcomes in acute respiratory failure. Keywords: Esophageal balloon manometry, Transpulmonary pressures, dyssynchronies, closed-loop ventilation.
Guillain- Barre Syndrome (GBS) is an autoimmune condition that can cause life-threatening respiratory failure, necessitating prolonged mechanical ventilation (MV). High flow oxygen can also be administered through a tracheostomy (HFOT) with an adapter, although evidence for its benefit in difficult-to-wean tracheostomized patients is scarce. A 60-year-old male with acute myeloid leukemia (AML) underwent allogeneic stem cell transplantation and achieved complete remission. Six months later, he developed GBS involving limb and respiratory muscle paralysis. Negative inspiratory force was -15 cm H2O. He required endotracheal intubation, tracheostomy, and treatment with Rituximab and immunoglobulin. For more than two months on the ventilator repeated trials of tracheostomy collar were unsuccessful. After 78 days on the ventilator, HFOT via tracheal adapter with 50% FiO2 at 60 L/min was introduced daily, initially for 1h for the first couple of days, then 3h twice a day, and increased as tolerated to 24 h. After 99 days of either intermittent or continuous ventilator support, he tolerated 24 h off ventilator on HFOT and was transitioned to tracheostomy collar, decannulated, and discharged to rehab after five months. Our case highlights successful use of high flow oxygen via tracheostomy (HFOT) in a difficult-to-wean patient with Guillain-Barre Syndrome.
Background Esophageal balloon manometry is a surrogate for pleural pressure and has been in clinical use for decades. The main advantages for its use are to partition the total lung and chest wall mechanics, thus providing transpulmonary inspiratory, expiratory, and driving pressure monitoring as the true stress delivered to the lung, and the capability to measure the transpulmonary mechanical power as the true energy delivered to inflate the lungs. Thus, it can provide more insight into lung and diaphragmatic protective ventilation than total airway pressure alone. Its capability as the gold standard to measure patient effort, muscle pressure, and to diagnose patient-ventilator interactions and dyssynchronies adds further value to its usage. Proposed Framework As the paradigm shifts toward personalized lung and diaphragm-protective ventilation, alongside increased recognition of ventilator-induced and patient self-inflicted lung injury (VILI and P-SILI respectively), using esophageal balloon manometry seems to be the ultimate tool to achieve these goals. In this paper, we introduce an automated theoretical closed-loop ventilation mode that is based on adjusting the inspiratory and expiratory transpulmonary pressures to a safe zone to provide true individualized lung and diaphragmatic protective ventilation, while simultaneously adjusting the triggering, maintaining, and cycling of breaths according to the patient's neural time and effort, potentially detecting and eliminating dyssynchronies. Clinical Implications This adaptive mode aims to optimize the balance between lung recruitment, overdistension, and respiratory muscle unloading, addressing VILI, P-SILI, ventilator induced diaphragm dysfunction (VIDD) and dyssynchronies. Conclusion The theoretical esophageal pressure guided closed-loop ventilation based on continuous input and feedback from the esophageal balloon represents a physiologically attractive framework toward individualized lung and diaphragm protective ventilation can conceptually lead to safer personalized ventilation, significantly lessen dyssynchronies, and potentially improve mortality outcomes in acute respiratory failure. However, this concept remains theoretical and unvalidated. Future studies are required before claims regarding feasibility, safety and outcome benefits can be made.
Resistance to paradigm shifts is a common issue in medicine, often delaying the adoption of new therapies despite strong evidence. This perspective explores how medical treatments can transition from being evidence based practices to rigid dogma. Lung-protective ventilation for acute respiratory distress syndrome (ARDS) exemplifies this challenge. We outline a sequence by which a single influential clinical trial can crystallize into an unquestioned standard of care. The low-tidal-volume ARDSNet strategy, established by a landmark randomized controlled trial (RCT) over twenty-five years ago, exemplifies this process. Reanalyzing the same data used in the ARDSNet RCT demonstrated that low tidal volume ventilation is not lung-protective in all patient subgroups and may even increase mortality. Despite data clearly demonstrating that the ARDSNet strategy can be harmful and that there has been no reduction in ARDS related mortality over three decades of use, the method remains the standard of care. Indeed, the most recent Guidelines papers published in multiple leading medical journals still strongly recommend low tidal volume for ARDS patients. This paper argues that the continued dominance of a single paradigm can hinder innovation and delay the adoption of life-saving treatments. Improvements in ARDS management and medicine overall require ongoing reassessment of established practices, openness to new evidence, and the courage to challenge accepted dogma.
The mechanical behavior of lung tissue, especially under pathological conditions such as acute respiratory distress syndrome (ARDS), cannot be fully described by simple elastic or viscous models. Instead, the lung exhibits viscoelastic properties that depend on both the rate and duration of deformation. Integer-order viscoelastic models, including the Maxwell, Kelvin-Voigt, Zener, Anti-Zener, and Burgers models, have historically provided a conceptual framework for understanding lung mechanics by representing tissue as combinations of springs and dashpots governed by first- or second-order differential equations. These models are valuable for educational purposes and initial clinical interpretation, allowing quantification of phenomena such as stress relaxation and creep. However, their main limitation lies in their inability to capture the continuous distribution of relaxation times and the power-law response observed in biological tissues, particularly in heterogeneous and injured lungs as seen in ARDS. More complex models, such as the generalized Maxwell model, offer improved accuracy but at the cost of increased mathematical complexity and parameterization, restricting their routine clinical use. Recent evidence suggests that fractional-order models may provide a more physiologically accurate and parsimonious description of lung viscoelasticity, capturing frequency dependence and long-term responses with fewer parameters. The development of advanced models is essential for optimizing protective ventilation strategies and understanding the mechanisms underlying ventilator-induced lung injury.
Background Patient–ventilator dyssynchrony is a frequent and clinically relevant phenomenon during mechanical ventilation and has been associated with increased work of breathing, longer duration of ventilation, and worse outcomes. Although positive end-expiratory pressure (PEEP) is a cornerstone of ventilatory management to improve oxygenation and alveolar stability, its potential role in modulating of patient–ventilator interaction patterns and dyssynchrony has received comparatively little attention. Objective To provide a narrative review of the physiological mechanisms by which PEEP may influence patient–ventilator interaction patterns and dyssynchronies, integrating the available clinical and experimental evidence, including indirect data derived from studies on respiratory mechanics, auto-PEEP, and ventilatory interaction. Methods A non-systematic narrative review of the literature was conducted, focusing on studies addressing patient–ventilator interaction, auto-PEEP, respiratory mechanics, and the clinical consequences of dyssynchrony. When direct evidence linking PEEP to specific patterns of dyssynchrony was lacking, physiological inferences were drawn from related studies, and the rationale for these extrapolations is explicitly discussed. Results PEEP influences key determinants of patient–ventilator interaction, including end-expiratory lung volume, transpulmonary pressure, inspiratory threshold load, and expiratory time. Appropriately titrated PEEP may reduce ineffective efforts by partially counterbalancing intrinsic PEEP, stabilizing alveolar units, and attenuating excessive inspiratory effort. Conversely, excessive or insufficient PEEP may exacerbate dyssynchrony by promoting air trapping, flow limitation, or premature cycling. Although most of the available evidence is indirect, consistent physiological principles support a significant modulatory role of PEEP in the development and resolution of various patient-ventilator interaction patterns and dyssynchronies. Conclusion PEEP should be considered not only as a tool for oxygenation and respiratory mechanics, but also as a potential modulator that should be personalized to improve patient-ventilator interaction. Prospective studies specifically designed to evaluate the impact of PEEP on dyssynchrony are needed to guide more individualized ventilatory strategies.
Care bundles have been introduced into practice to prevent ventilator-associated pneumonia (VAP) in critically ill adults. The Institute for Healthcare Improvement (IHI) proposed a worldwide implementation of the “IHI ventilator bundle” consisting of interventions to reduce the rate of VAP. Updates to these clinical practice bundles occur based on new evidence yet change within institutions is lagging. This review aims to discuss the latest updates in clinical evidence on the pharmacotherapy included in these bundles to aid institutional quality improvement measures. The 2022 Society for Healthcare Epidemiology (SHEA) practice recommendations for preventing VAP were used to identify key pharmacotherapy interventions that are commonly incorporated into hospital care bundles. Three interventions were focused on for this review: (1) Multimodal sedation and analgesia strategies; (2) Oral care with chlorhexidine; and (3) Stress ulcer prophylaxis. A comprehensive literature search was conducted utilizing PubMed, focusing on MeSH terms involving the interventions identified for further review. Literature published from August 2021 to September 2024 was focused on for this project. Findings from these studies were reviewed, summarized, and compared alongside the corresponding 2022 SHEA/IDSA/APIC update recommendations to either reinforce or challenge current VAP bundle practices. This literature review identified a correlation with the pharmacotherapy interventions recommended in the 2022 SHEA/IDSA/APIC update on current VAP bundle practices. The findings support the preferential use of non-benzodiazepine sedatives associated with better clinical outcomes. Additionally, chlorhexidine for oral care with toothbrushing is not recommended due to a lack of strong evidence supporting its effectiveness in reducing VAP rates. Conflicting evidence regarding stress-ulcer prophylaxis remains, warranting the need for further high-quality studies to draw definitive conclusions. Overall, healthcare facilities should ultimately continue to prioritize quality improvement and stay informed on the latest recommendations to effectively prevent VAP. Keywords: Ventilator associated pneumonia, ventilator bundle, sedation, stress ulcer prophylaxis
Transfusion-related acute lung injury (TRALI) is a severe, life-threatening complication of blood products transfusion characterized by acute hypoxemia and non-cardiogenic pulmonary edema, typically within six hours following transfusion of blood products. It is a highly morbid complication in critically ill patients, particularly those with pre-existing lung injury or systemic inflammation. TRALI remains frequently under-reported due to diagnostic challenges, mainly attributable to the absence of validated confirmatory tests, resulting in diagnostic uncertainty, delayed recognition, and unfavorable clinical outcomes. The present review represents an extensive literature search for evidence related to the diagnostic utility of novel biomarkers, including interleukin-8, soluble intracellular adhesion molecules, and a review of existing data on management strategies in the critical care setting, including the role of mechanical ventilation, non-invasive ventilation, and the potential roles of immunomodulatory therapies. Through a focused lens on critically ill populations, this review aims to clarify the current TRALI diagnosis and management landscape while highlighting areas for ongoing investigation.
Background Heart-lung interactions represent a fundamental physiological relationship that determines the hemodynamic and respiratory responses in both healthy and critically ill patients. In the intensive care setting, understanding these interactions is essential for optimizing ventilation and circulatory support. Objective This article provides a comprehensive review of the physiological and pathophysiological mechanisms underlying heart-lung interactions during spontaneous, controlled, and assisted ventilation, with a focus on disease specific implications in chronic obstructive, restrictive pulmonary disease, and heart failure. Methods A narrative synthesis of current evidence and guideline-based practices was conducted, integrating data from recent clinical and experimental studies on cardiopulmonary coupling, hemodynamic monitoring, and mechanical ventilation strategies. Results Spontaneous breathing enhances venous return and right ventricular preload through negative intrathoracic pressure but increases left ventricular afterload. Conversely, controlled mechanical ventilation reduces preload while alleviating left ventricular afterload through positive intrathoracic pressures. In obstructive patients, dynamic hyperinflation and auto-PEEP elevate right ventricular afterload and reduce cardiac output. In restrictive patients, high PEEP and driving pressures exacerbate pulmonary vascular resistance and right heart strain, whereas in heart failure, positive pressure ventilation reduces pulmonary congestion and left ventricular afterload, improving cardiac output. Assisted modes modulate these effects depending on the patient's spontaneous effort, synchronization, and underlying pathophysiology. Conclusion Heart-lung interactions must be dynamically assessed to individualize ventilatory and hemodynamic strategies. Advanced monitoring, personalized ventilation, and AI-assisted decision systems represent the future of optimizing cardiopulmonary coupling in critically ill patients, improving survival and minimizing ventilator-induced injury.
Mechanical ventilation is a lifesaving intervention and represents one of the most important treatments ever introduced in intensive care units, but it can cause lung damage if not used properly, knowledge of each mode is prudent for a safe utilization. Intermittent mandatory ventilation is a type of breath sequence in which you can see spontaneous and mandatory breaths coexisting in different manners. It can serve all three basic goals of mechanical ventilation: safety, comfort, and liberation. Taxonomic attribute grouping abbreviates the ventilation mode that has three components: control variable; ventilation sequence; and target control scheme. It clarifies the mode's operation and mechanics. We’ll review two less usual ventilatory modes with two different types of IMV breath sequence (type 1 and 2): BIPAP (Dräger) and Automode (Maquet-Getinge).
Background Ventilator-associated pneumonia (VAP) remains a common and serious complication among patients receiving invasive mechanical ventilation. Inhaled antibiotics have been proposed as a strategy to either prevent or treat VAP by achieving high local concentrations in the lung with minimal systemic toxicity. However, their clinical benefit and optimal use remain uncertain. Objective This review aims to summarize current evidence on the use of inhaled antibiotics for both the prevention and treatment of VAP, identify existing knowledge gaps, and suggest directions for future research. Methods A narrative synthesis was conducted based on a comprehensive review of randomized controlled trials, meta-analyses, and observational studies published up to 2024. Particular attention is given to antibiotic class, delivery method, patient outcomes, safety, and microbial resistance. Findings Several high-quality studies suggest that prophylactic inhaled antibiotics, especially aminoglycosides such as amikacin, significantly reduce the incidence of VAP without increasing adverse events or multidrug resistance. Nonetheless, consistent improvements in mortality, ICU length of stay, or duration of mechanical ventilation have not been demonstrated. In the treatment context, inhaled antibiotics are frequently used as adjunctive therapy for multidrug-resistant Gram-negative pathogens, although robust RCT evidence remains limited. Key challenges include heterogeneity in study design, delivery devices, antibiotic regimens, and diagnostic definitions of VAP. Conclusions Inhaled antibiotics appear effective in preventing VAP, particularly when delivered via modern nebulization systems. However, their role in improving patient-centered outcomes and in the treatment of established VAP requires further clarification. Future research should focus on standardized protocols, long-term safety monitoring, and identifying patient subgroups most likely to benefit. Well-designed trials powered for clinical outcomes are essential to support the broader integration of inhaled antibiotics into VAP management strategies.
Asynchronies during mechanical ventilation, particularly reverse triggering (RT), is a common phenomenon in critically ill patients, with prevalence estimates between 30% and 60%. RT is characterized by the activation of respiratory muscles induced by the passive insufflation, which can impact pulmonary physiology and diaphragmatic function, increasing the risk of lung injury and muscle damage. The proposed classification of RT in this article is based on five key criteria which suppose a structured evaluation of RT phenotypes. This classification criteria would allow differentiation between events that may be beneficial, such as maintaining diaphragm activity and improving oxygenation, and injurious episodes, including breath stacking and high efforts that exacerbate pulmonary and muscular injury. Understanding and classifying RT in detail enables clinicians to make more precise decisions and implement personalized interventions, thereby improving the safety and effectiveness of mechanical ventilation in critical care settings. This comprehensive approach provides a foundation for future research to validate its clinical utility, identify high-risk patient phenotypes, and develop targeted therapies.
The dynamic processes associated with lung pathophysiology have always been explored from a traditionalist perspective. This review conceptualizes an amalgam of biological and biophysical concepts that aim to optimize the understanding of the pathophysiology associated with lung injury from a broader, more complex, and at the same time more complete perspective using arguments from the exact sciences. We hypothesize that the Anti-Zener model could be a more accurate potential explanatory model to support mechanotransduction. The Anti-Zener model represents a more accurate and structured tool to describe the viscoelastic behavior of lung tissue, overcoming the limitations of classical models such as Young's modules This approach allows a better understanding of pathophysiological processes in the respiratory system, which could optimize treatments for lung diseases such as ARDS and asthma. The integration of exact sciences in the study of lung viscoelasticity opens new possibilities for improving medical care and the design of biomedical materials.
Weaning or liberation from mechanical ventilation is an important goal for critical care patients and in many cases this process spends most of the time in intensive care units. The optimal strategy to wean critical care patients isn’t elucidated. Computerized or automated weaning has been used to improve this process. Taxonomy of a ventilatory mode includes mention of the control variable, breath sequence, and targeting scheme. Intermittent mandatory ventilation (IMV) is a type of breath sequence in which it coexists spontaneous and mandatory breaths. It could be used for weaning in some patients. There are five varieties of IMV each with its own advantages and disadvantages. We’ll review two less usual ventilatory modes with IMV breath sequence: mandatory minute ventilation (Draeger) and its evolution, adaptive ventilation mode, specifically adaptive minute ventilation (Mindray).
Introduction Exacerbations of interstitial lung disease (ILD), diffuse parenchymal lung diseases, or idiopathic pulmonary fibrosis can often lead to acute hypoxia, resulting in intensive care unit (ICU) admission. For those patients who require invasive mechanical ventilation, mortality rates can exceed 80%. Methods This review discusses the fundamental aspects of ILD exacerbations in the ICU setting, comprising diagnostic modalities, criteria, and management options. These include high-resolution computerized tomography, sputum analysis, treatment with immunomodulating agents, and both non-invasive and invasive ventilatory support strategies. Conclusion Exacerbations of ILD requiring mechanical ventilation are associated with poor prognostic outcomes. Understanding diagnostic criteria and treatment options is crucial to studying the high morbidity & mortality rates, leading to future directions focused on delivery of optimal care for this vulnerable patient population.
Biopolymers are synthetic macromolecules that can cause multiple complications, both local and systemic, which can manifest immediately or years later. Complications of biopolymer administration are increasingly common. They can present as silicone embolization syndrome (SES), pneumonitis, diffuse alveolar hemorrhage, and in their most severe form as acute respiratory distress syndrome (ARDS).
Introduction Patient–ventilator asynchronies (PVA) are common in intensive care units and are associated with adverse outcomes, such as increased work of breathing, higher sedation requirements, and prolonged mechanical ventilation. Despite the availability of ventilator waveform monitoring, clinical recognition of PVA remains low. This highlights the need for innovative educational strategies to improve interpretation and response. Objective To propose a visual analogy termed the “Batman sign” as a mnemonic tool to support the teaching and recognition of complex PVA. Methods Clinical waveform data were analyzed to identify a distinctive pattern in the pressure–time curve caused by the simultaneous presence of two asynchronies: excessive flow and delayed cycling. The resulting morphology resembles the frontal silhouette of the fictional character Batman, with two symmetrical peaks evoking his ears. This analogy served as the foundation for a visual teaching strategy aimed at improving PVA recognition among clinicians in training. Results: We describe the physiological and waveform features of each asynchrony, their clinical implications, and their combined presentation as the “Batman sign.” By incorporating dual coding theory and principles of meaningful learning, this visual resource enhances the understanding of complex ventilatory events. Illustrative figures support the practical application of the concept. Conclusion The “Batman sign” represents an innovative pedagogical approach that integrates visual and clinical reasoning to improve mechanical ventilation education. Its application may enhance diagnostic competency, foster knowledge retention, and support clinical decision-making in high-acuity care settings. Further validation in training programs is recommended.
