Management of patients with severe lung injury: first, do no harm

Severe acute lung injury may result from many infectious and other insults. Although the initial insult may cause overwhelming tissue damage with subsequent gas exchange impairment and risk of death, several strategies of management may also add substantial toxicity. This review focuses on damage incurred by recently identified toxic ventilator settings e.g., high inflation pressures, too low settings of positive end-expiratory pressure, and too high tidal volumes. Liberal fluid management may be another important source of toxicity. The evidence from the literature for survival advantage of lung protective and other strategies is critically reviewed.