Learning objectives

• Understand the basic principles behind lung protective ventilation

Definition 

• Lung protective ventilation (LPV) is a ventilation strategy aiming to reduce pulmonary complications after mechanical ventilation
• Perioperative lung injury is a spectrum of disease that includes inflammation, impaired gas exchange, radiographic abnormalities, and respiratory failure
• It is reasonable to use LPV as the default ventilation strategy in all mechanically ventilated patients

Ventilator settings (management)

• Tidal volume of 6-8 mL/kg predicted body weight
• Plateau pressures <30 cm H2O
• Start positive end-expiratory pressure (PEEP) at 5 cm H2O
• When performing recruitment maneuvers use:
  • The lowest effective pressure
  • The shortest effective time
  • The least amount of breaths 

Keep in mind

• Ventilator induced lung injury (VILI) occurs via:
  • Volutrauma: high tidal volumes
  • Barotrauma: high inspiratory pressures
  • Atelectotrauma: repetitive and rapid opening of the alveoli
  • Biotrauma:
    • Inflammatory damage
    • Apoptotic/fibroproliferative processes
    • The translocation of bacteria and pro-inflammatory mediators
• VILI shares common pathophysiological features with acute respiratory distress syndrome (ARDS)
• ARDS is caused by:
  • Pneumonia, sepsis, or aspiration pneumonitis (in 85% of cases)
  • Blood transfusion, hemorrhagic shock, burns, inhalation injury
  • Surgical factors: trauma, retraction injury, cardiopulmonary bypass, and ischemia-reperfusion injury
• VILI occurs most often in patients with predisposing factors for ARDS
• In patients at risk for ARDS or with ARDS, LPV;
  • Improves oxygenation and pulmonary physiology
  • Reduces postoperative pulmonary complications
  • Reduces the relative risk of death at day 28 

Suggested reading

• Young CC, Harris EM, Vacchiano C, et al. Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations. Br J Anaesth. 2019;123(6):898-913.
• O’Gara B, Talmor D. Perioperative lung protective ventilation. BMJ. 2018;362:k3030. Published 2018 Sep 10. doi:10.1136/bmj.k3030
• Beitler JR, Malhotra A, Thompson BT. Ventilator-induced Lung Injury. Clin Chest Med. 2016;37(4):633-646.
• Petrucci N, De Feo C. Lung protective ventilation strategy for the acute respiratory distress syndrome. Cochrane Database Syst Rev. 2013;2013(2):CD003844. Published 2013 Feb 28.

Clinical updates

van den Berg et al. (Current Opinion in Critical Care, 2025) describe a comprehensive strategy for achieving lung- and diaphragm-protective ventilation that integrates noninvasive ventilator maneuvers—particularly airway occlusion pressure (Pocc)—to detect excessive respiratory effort and dynamic lung stress, with target ranges such as Pocc 7–15 cmH₂O and predicted dynamic transpulmonary pressure <22 cmH₂O. They highlight recent physiologic RCTs showing that systematic titration of inspiratory support and sedation can bring most patients within protective effort ranges, and propose a bedside Pocc-guided protocol to balance lung stress and diaphragm workload during the transition to assisted ventilation.

Hoshino et al. (Acute Medicine & Surgery, 2024) review ventilator-induced lung injury in ARDS and argue that mortality has plateaued despite low tidal volume (6 mL/kg) and plateau pressure limitation since ARMA, with only prone positioning and early neuromuscular blockade consistently improving survival in severe ARDS. They propose shifting from “one-size-fits-all” ventilation to precision strategies that individualize tidal volume using driving pressure and tailor PEEP based on lung recruitability (recruitment-to-inflation ratio), esophageal balloon-guided transpulmonary pressure targeting (expiratory transpulmonary pressure ≈0 cmH₂O), and electrical impedance tomography to balance collapse and overdistension.