The aetiology, consequences and prevention of barotrauma: a critical review of the literature

Purpose: To review critically the literature on pulmonary barotrauma in mechanically ventilated patients. Methods: Data sources included MEDLINE and citation lists of relevant articles. Articles investigating the aetiology or prevention of pulmonary barotrauma were critically evaluated according to published guidelines. Results: Experimental animal studies and observational clinical studies consistently demonstrate that the high airway pressures and large tidal volumes associated with conventional modes of mechanical ventilation are major contributors to lung injury. Animal studies establish the correct temporal relationship and demonstrate a biological gradient. Observational clinical studies demonstrate an increased risk of barotrauma in the setting of acute lung injury. The results of three case series and two small randomised clinical trials indicate that a pressure-limited ventilation strategy aimed to reduce barotrauma may improve outcomes in patients with acute lung injury. Conclusions: Pulmonary barotrauma is a clinically important phenomenon that may delay the healing of injured lungs and lead to the development, or the exacerbation, of ARDS. Risk factors for barotrauma include high peak airway pressures, large tidal volumes and acute lung injury. Resolution of the role for pressure-limited ventilation in ARDS prevention and treatment requires a large-scale randomised clinical trial.