Ventilator-induced lung injury: from mechanisms to integrated clinical management

Currently, there are no definitive diagnostic criteria for Ventilator-induced lung injury (VILI), and the mechanisms underlying its development and progression remain incompletely understood. These mechanisms involve a complex interplay of factors, including barotrauma, volutrauma, atelectrauma, and biotrauma. Central to these issues are excessive lung tissue distension, the cyclic opening and closing of alveoli, and the activation and release of inflammatory mediators. Moreover, emerging concepts such as patient self-inflicted lung injury (P-SILI) and mechanical power have further expanded our understanding of VILI. These concepts underscore the critical roles of respiratory drive and mechanical energy transfer in the injury process. An in-depth analysis of the mechanisms underlying VILI suggests that its clinical prevention requires a dynamic and phase-specific strategy throughout the entire mechanical ventilation process. During the controlled ventilation phase, the primary focus should be on implementing a lung-protective ventilation strategy, which includes the use of low tidal volume and driving pressure, individualized positive end-expiratory pressure titration, prone positioning and extracorporeal life support to minimize pulmonary stress and strain. In the transition phase, attention should shift to modulating respiratory drive and ensuring optimal patient-ventilator synchrony to prevent P-SILI. Finally, during the weaning phase, emphasis should be placed on systematic assessment and spontaneous breathing trials to achieve safe liberation from mechanical ventilation. Here, we summarize the main mechanisms underlying VILI and outline prevention strategies to enhance understanding and management of this complication among clinical healthcare providers, ultimately to improve patient clinical outcomes.