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Semin Respir Crit Care Med 2022; 43(03): 369-378
DOI: 10.1055/s-0042-1744303
Review Article

Asymmetrical Lung Injury: Management and Outcome

Luca Bastia
1   Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
2   Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
3   Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
,
Hadrien Rozé
4   Thoracic Surgery and Lung Transplant Unit, Department of Anesthesiology and Critical Care, Bordeaux University Hospital, Haut Leveque Hospital, Pessac, France
5   Centre de Recherche Cardio Thoracique INSERM 1045, Pessac, France
,
Laurent J. Brochard
2   Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
3   Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
6   Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Canada
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Abstract

Among mechanically ventilated patients, asymmetrical lung injury is probably extremely frequent in the intensive care unit but the lack of standardized measurements does not allow to describe any prevalence among mechanically ventilated patients. Many past studies have focused only on unilateral injury and have mostly described the effect of lateral positioning. The good lung put downward might receive more perfusion while the sick lung placed upward receive more ventilation than supine. This usually results in better oxygenation but can also promote atelectasis in the healthy lung and no consensus has emerged on the clinical indication of this posture. Recently, electrical impedance tomography (EIT) has allowed for the first time to precisely describe the distribution of ventilation in each lung and to better study asymmetrical lung injury. At low positive-end-expiratory pressure (PEEP), a very heterogeneous ventilation exists between the two lungs and the initial increase in PEEP first helps to recruit the sick lung and protect the healthier lung. However, further increasing PEEP distends the less injured lung and must be avoided. The right level can be found using EIT and transpulmonary pressure. In addition, EIT can show that in the two lungs, airway closure is present but with very different airway opening pressures (AOPs) which cannot be identified on a global assessment. This may suggest a very different PEEP level than on a global assessment. Lastly, epidemiological studies suggest that in hypoxemic patients, the number of quadrants involved has a strong prognostic value. The number of quadrants is more important than the location of the unilateral or bilateral nature of the involvement for the prognosis, and hypoxemic patients with unilateral lung injury should probably be considered as requiring lung protective ventilation as classical acute respiratory distress syndrome.

Keywords

acute respiratory failure - pneumonia - mechanical ventilation - acute respiratory distress syndrome - respiratory mechanics - esophageal pressure


Publication History

Article published online:
04 July 2022

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