急性呼吸不全に対する人工呼吸戦略の潮流

In the second half of the 20th century, the polio epidemic led to dramatic advances in positive pressure mechanical ventilation. However, it has become known that mechanical ventilation itself exacerbates lung injury and increase mortality （ventilator-induced lung injury, VILI）. Over the past 20 years, numerous studies have been conducted to minimize the risk of VILI, and lung protective ventilation strategies consisting of low tidal volume, low plateau and driving pressure, and the use of appropriate end-expiratory positive pressure, became standard of care for acute respiratory distress syndrome （ARDS）.
Furthermore, in recent years, it has revealed that excessive respiratory effort exacerbates lung injury （patient self-inflicted lung injury, P-SILI）, and the importance of controlling excessive respiratory effort has been recognized. However, strong suppression of respiratory effort leads to diaphragm atrophy, which may affect patient outcomes. Therefore, lung- and diaphragm-protective ventilation, which consists of monitoring respiratory effort closely and maintaining the effort at an appropriate level, has been proposed as a concept to avoid diaphragm atrophy while preventing P-SILI.
Nevertheless, the mortality rate of ARDS is still high. Today, there is a need to move away from standardized treatment and to tailor ventilatory management to the individual risk of each patient.