• Heder J de Vries, Annemijn H Jonkman, Harm J de Grooth, Jan Willem Duitman, GirbesArmand R JARJDepartment of Intensive Care Medicine, Amsterdam UMC location VUmc, Amsterdam, the Netherlands., OttenheijmCoen A CCACAmsterdam Cardiovascular Sciences Research Institute, Amsterdam, the Netherlands.Department of Physiology, Amsterdam UMC location VUmc, Amsterdam, the Netherlands., Marcus J Schultz, Peter M van de Ven, Yingrui Zhang, Angelique M E de Man, Pieter R Tuinman, and HeunksLeo M ALMADepartment of Intensive Care Medicine, Amsterdam UMC location VUmc, Amsterdam, the Netherlands.Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, the Netherlands..
• Department of Intensive Care Medicine, Amsterdam UMC location VUmc, Amsterdam, the Netherlands.
• Crit. Care Med. 2022 Feb 1; 50 (2): 192203192-203.

ObjectivesLung- and diaphragm-protective ventilation is a novel concept that aims to limit the detrimental effects of mechanical ventilation on the diaphragm while remaining within limits of lung-protective ventilation. The premise is that low breathing effort under mechanical ventilation causes diaphragm atrophy, whereas excessive breathing effort induces diaphragm and lung injury. In a proof-of-concept study, we aimed to assess whether titration of inspiratory support based on diaphragm effort increases the time that patients have effort in a predefined "diaphragm-protective" range, without compromising lung-protective ventilation.DesignRandomized clinical trial.SettingMixed medical-surgical ICU in a tertiary academic hospital in the Netherlands.PatientsPatients (n = 40) with respiratory failure ventilated in a partially-supported mode.InterventionsIn the intervention group, inspiratory support was titrated hourly to obtain transdiaphragmatic pressure swings in the predefined "diaphragm-protective" range (3-12 cm H2O). The control group received standard-of-care.Measurements And Main ResultsTransdiaphragmatic pressure, transpulmonary pressure, and tidal volume were monitored continuously for 24 hours in both groups. In the intervention group, more breaths were within "diaphragm-protective" range compared with the control group (median 81%; interquartile range [64-86%] vs 35% [16-60%], respectively; p < 0.001). Dynamic transpulmonary pressures (20.5 ± 7.1 vs 18.5 ± 7.0 cm H2O; p = 0.321) and tidal volumes (7.56 ± 1.47 vs 7.54 ± 1.22 mL/kg; p = 0.961) were not different in the intervention and control group, respectively.ConclusionsTitration of inspiratory support based on patient breathing effort greatly increased the time that patients had diaphragm effort in the predefined "diaphragm-protective" range without compromising tidal volumes and transpulmonary pressures. This study provides a strong rationale for further studies powered on patient-centered outcomes.Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and Wolters Kluwer Health, Inc.

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