• Paolo Pelosi, Lorenzo Ball, BarbasCarmen S VCSVPneumology and Intensive Care Medicine, University of São Paulo, São Paulo, Brazil.Adult Intensive Care Unit, Albert Einstein Hospital, São Paulo, Brazil., Rinaldo Bellomo, BurnsKaren E AKEAInterdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.Unity Health Toronto-St. Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, ON, Canada., Sharon Einav, Luciano Gattinoni, John G Laffey, John J Marini, Sheila N Myatra, Marcus J Schultz, Jean Louis Teboul, and RoccoPatricia R MPRMLaboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil..
• Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy. ppelosi@hotmail.com.
• Crit Care. 2021 Jul 16; 25 (1): 250250.

AbstractA personalized mechanical ventilation approach for patients with adult respiratory distress syndrome (ARDS) based on lung physiology and morphology, ARDS etiology, lung imaging, and biological phenotypes may improve ventilation practice and outcome. However, additional research is warranted before personalized mechanical ventilation strategies can be applied at the bedside. Ventilatory parameters should be titrated based on close monitoring of targeted physiologic variables and individualized goals. Although low tidal volume (VT) is a standard of care, further individualization of VT may necessitate the evaluation of lung volume reserve (e.g., inspiratory capacity). Low driving pressures provide a target for clinicians to adjust VT and possibly to optimize positive end-expiratory pressure (PEEP), while maintaining plateau pressures below safety thresholds. Esophageal pressure monitoring allows estimation of transpulmonary pressure, but its use requires technical skill and correct physiologic interpretation for clinical application at the bedside. Mechanical power considers ventilatory parameters as a whole in the optimization of ventilation setting, but further studies are necessary to assess its clinical relevance. The identification of recruitability in patients with ARDS is essential to titrate and individualize PEEP. To define gas-exchange targets for individual patients, clinicians should consider issues related to oxygen transport and dead space. In this review, we discuss the rationale for personalized approaches to mechanical ventilation for patients with ARDS, the role of lung imaging, phenotype identification, physiologically based individualized approaches to ventilation, and a future research agenda.© 2021. The Author(s).

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