• Takeshi Yoshida, Amato Marcelo B P MBP Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil., Brian P Kavanagh, and Yuji Fujino.
• Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan.
• Curr Opin Crit Care. 2019 Apr 1; 25 (2): 192-198.

Purpose Of ReviewFacilitating spontaneous breathing has been traditionally recommended during mechanical ventilation in acute respiratory distress syndrome (ARDS). However, early, short-term use of neuromuscular blockade appears to improve survival, and spontaneous effort has been shown to potentiate lung injury in animal and clinical studies. The purpose of this review is to describe the beneficial and deleterious effects of spontaneous breathing in ARDS, explain potential mechanisms for harm, and provide contemporary suggestions for clinical management.Recent FindingsGentle spontaneous effort can improve lung function and prevent diaphragm atrophy. However, accumulating evidence indicates that spontaneous effort may cause or worsen lung and diaphragm injury, especially if the ARDS is severe or spontaneous effort is vigorous. Recently, such effort-dependent lung injury has been termed patient self-inflicted lung injury (P-SILI). Finally, several approaches to minimize P-SILI while maintaining some diaphragm activity (e.g. partial neuromuscular blockade, high PEEP) appear promising.SummaryWe update and summarize the role of spontaneous breathing during mechanical ventilation in ARDS, which can be beneficial or deleterious, depending on the strength of spontaneous activity and severity of lung injury. Future studies are needed to determine ventilator strategies that minimize injury but maintaining some diaphragm activity.

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