Acute respiratory distress syndrome and spontaneous breathing in children: To breathe or not to breathe

Mechanical ventilation is a life-saving intervention and is used to fully or partially take over gas exchange and reduce the patient's work of breathing. However, ventilation can also lead to serious complications that affect patient outcomes. While spontaneous breathing during ventilation is associated with various benefits—such as better distribution of ventilation to the dorsal, well-perfused lung regions, thereby reducing shunt fraction and the inflammatory response—it can also exacerbate lung injury. Strong breathing efforts can lead to high transpulmonary pressures. Transpulmonary pressures can be estimated non-invasively by measuring esophageal pressure using a balloon catheter. Our study shows that individualized titration of balloon volume is important for the reliability of these measurements. An end-expiratory occlusion maneuver can provide an indication of respiratory drive and the risk of high transpulmonary pressures. To prevent breathing efforts from causing additional harm, neuromuscular blocking agents can be used to eliminate all spontaneous efforts. The use of neuromuscular blocking agents in children with acute respiratory distress syndrome (ARDS) has not been proven effective. Although we initiated a randomized controlled trial, this trial was terminated early due to slow enrollment. Therefore, it remains uncertain whether the use of neuromuscular blocking agents in children with ARDS is effective, but this thesis helps to identify children at risk of additional lung injury due to spontaneous breathing, a phenomenon known as patient self-inflicted lung injury (P-SILI).