New aspects of ventilation in acute lung injury

Recent recognition that artificial ventilation may cause damage to the acutely injured lung has caused renewed interest in ventilation techniques that minimise this potential harm. Many ventilation techniques have proved beneficial in small trials of very specific patient groups, but most have subsequently failed to translate into improved patient outcome in larger trials. An exception to this is 'protective ventilation' using reduced tidal volumes (to lower airway pressure) and increased PEEP (to reduce pulmonary collapse). Results of trials of protective ventilation have been encouraging, and the technique should now be adopted more widely. High frequency ventilation, inverse ratio ventilation, prone positioning and inhaled nitric oxide are all techniques that may be considered when, in spite of optimal artificial ventilation, the patient's gas exchange remains dangerously poor. Under these circumstances, the choice of technique is dependent on their availability, local expertise and individual patient needs.