Beyond One-Size-Fits-All: Precision Mechanical Ventilation in ARDS.

Area of Science:

• Critical Care Medicine
• Pulmonary Medicine
• Mechanical Ventilation

Background:

• Traditional Acute Respiratory Distress Syndrome (ARDS) management uses standardized mechanical ventilation, which may be imprecise due to patient heterogeneity.
• Individual differences in lung size, mechanics, and inflammatory responses necessitate personalized approaches.
• Current protocols may not adequately address the dynamic and heterogeneous nature of ARDS, potentially leading to harm.

Purpose of the Study:

• To review the evolution from conventional lung-protective ventilation to a precision-based paradigm for ARDS.
• To discuss principles of precision ventilation, including functional lung size, driving pressure, and mechanical power.
• To explore bedside tools and future strategies for individualizing mechanical ventilation in ARDS.

Main Methods:

• Narrative review of current evidence on ARDS heterogeneity and precision ventilation.
• Conceptualization of ARDS as a dynamic spectrum with a heterogeneous mechanical system.
• Evaluation of subphenotyping strategies (mechanical, biological, radiological) and bedside tools.

Main Results:

• ARDS exhibits significant heterogeneity in lung size, mechanics, and response to ventilation.
• Precision ventilation aligns support with individual patient physiology, moving beyond rigid targets.
• Bedside tools like esophageal pressure monitoring and lung ultrasound can aid in operationalizing precision ventilation.

Conclusions:

• Precision mechanical ventilation offers a more tailored and effective approach to ARDS management.
• Integrating patient-specific physiology and dynamic monitoring is crucial for optimizing outcomes.
• Future directions include predictive and adaptive ventilation strategies guided by real-time data.