Intensive Care Med (2016) 42:663673

DOI 10.1007/s00134-015-4200-8

Luciano Gattinoni
John J. Marini
Antonio Pesenti
Michael Quintel
Jordi Mancebo
Laurent Brochard

Received: 3 November 2015

Accepted: 18 December 2015
Published online: 18 January 2016
Springer-Verlag Berlin Heidelberg and
ESICM 2016
Take-home message: The baby lung was
originally defined as the fraction of lung
parenchyma that still maintains normal
inflation with near normal mechanical
characteristics despite at least a part of the
well-aerated baby lung is inflamed. The
baby lung is not an anatomical but a
functional entity which changes dimensions
and location with prone position and PEEP
application. Particular attention should be
paid to the general principles regulating the
safety of ventilation during both mechanical
ventilation and spontaneous breathing.

REVIEW

The baby lung became an adult

L. Gattinoni  A. Pesenti
Dipartimento di Fisiopatologia
Medico-Chirurgica e dei Trapianti,
Universita` degli Studi di Milano,
Via Francesco Sforza 35,
20122 Milan, Italy
J. J. Marini
Department of Medicine, University of
Minnesota, Minneapolis, Saint Paul, MN,
USA
e-mail: John.J.Marini@HealthPartners.Com
M. Quintel
Department of Anesthesiology, Emergency
and Intensive Care Medicine, Georg-August
University of Gottingen, Gottingen,
Germany
e-mail: mquintel@med.uni-goettingen.de

J. Mancebo
Servicio de Medicina Intensiva, Hospital de
L. Gattinoni ())  A. Pesenti
la Santa Creu i Sant Pau, Barcelona, Spain
Dipartimento di Anestesia, Rianimazione ed e-mail: JMancebo@santpau.cat
Emergenza Urgenza, Fondazione IRCCS Ca`
GrandaOspedale Maggiore Policlinico,
L. Brochard
Milan, Italy
Keenan Research Centre, Li Ka Shing
e-mail: gattinon@policlinico.mi.it
Knowledge Insitute, Critical Care
Tel.: ?39-02-55033232
Department, St. Michaels Hospital,
Toronto, ON, Canada
A. Pesenti
e-mail: BrochardL@smh.ca
e-mail: antonio.pesenti@unimi.it

L. Brochard
Interdepartmental Division of Critical Care
Medicine, Toronto, ON, Canada

Abstract The baby lung was originally defined as the fraction of lung
parenchyma that, in acute respiratory
distress syndrome (ARDS), still
maintains normal inflation. Its size
obviously depends on ARDS severity
and relates to the compliance of the
respiratory system. CO2 clearance
and blood oxygenation primarily
occur within the baby lung. While the
specific compliance suggests the
intrinsic mechanical characteristics to
be nearly normal, evidence from
positron emission tomography suggests that at least a part of the wellaerated baby lung is inflamed. The
baby lung is more a functional concept than an anatomical one; in fact,
in the prone position, the baby lung
shifts from the ventral lung
regions toward the dorsal lung
regions while usually increasing its
size. This change is associated with

664

better gas exchange, more homogeneously distributed trans-pulmonary

forces, and a survival advantage.
Positive end expiratory pressure also
increases the baby lung size, both
allowing better inflation of already
open units and adding new pulmonary
units. Viewed as surrogates of stress

Introduction

and strain, tidal volume and plateau

pressures are better tailored to baby
lung size than to ideal body weight.
Although less information is available
for the baby lung during spontaneous
breathing efforts, the general principles regulating the safety of

ventilation are also applicable under

these conditions.
Keywords ARDS  Baby lung 
Transpulmonary pressure 
Prone position  Stress and strain

expiratory pressure (PEEP), stress and strain, and spontaneous breathing may be considered according to the
Several diseases may produce the syndrome called acute baby lung model, as we explore in this paper.
respiratory distress syndrome (ARDS). The symptoms
involved are impaired gas exchange, decreased lung
compliance, increased lung weight and widespread
involvement of the lung parenchyma. Whatever the cause Baby lung: anatomical characteristics
of ARDS, the treatment of symptoms is mandatory to buy
time for the resolution of the underlying process, such as The concept of baby lung originated from observations
pneumonia or sepsis. Possible harm from mechanical on the first CT scan images obtained in ARDS patients,
ventilation is understandable if the ARDS lung is modeled which showed that densities were preferentially distributed
in two regions, one nearly normal and having dimensions in the dependent lung regions while the non-dependent lung
similar to those of a healthy baby (Fig. 1). The restricted regions were relatively spared. This view deeply contrasts
capacity of this baby lung is primarily responsible for with the common belief, derived from antero-posterior
the mechanical characteristics described in ARDS. The imaging, that ARDS homogeneously involves the entire
second region, consolidated and collapsed, is primarily lung parenchyma. Quantitative analysis of the CT scan (see
responsible for the impairment of oxygenation. This Fig. 2) [1] showed that the patho-anatomy of the ARDS
concept evolved over several decades: the baby lung, lung is not homogeneously distributed but comprised of
rather than an anatomical reality, became a functional regions totally deprived of air and regions normally (or
status. Studies relating to prone positioning, positive end- almost normally) aerated. Only a small proportion of the
lung is ventilated, and this small (baby) lung has to fulfill
the physiological needs of an adult body.
Quantitatively, the baby lung includes the voxels
comprised in the interval between -900 and -500
Hounsfield units (HU) [2], which describe the densities of
the voxel, where -900 indicates 90 % gas and 10 %
tissue and -500 indicates 50 % gas and 50 % tissue. In
normal lungs, the voxels included in this interval (the
well-inflated tissue) correspond to a weight of about
600700 g, while in ARDS they may account for 1/3 or
even 1/5 of this value. Quantitative analysis of the CT
scan provided a powerful tool to compare the in vivo
anatomy with the physiological variables commonly
measured in the ARDS definition. The most important
finding was the discovery that the aerated ARDS lung was
not stiff but small, with near normal intrinsic mechanical
characteristics [2]. The ratio of the respiratory system
compliance to the residual healthy (baby) lung (expressed as a fraction of the expected healthy lung volume)
Fig. 1 A representative CT scan image of an ARDS patient is roughly 1:1, i.e. 20 mL/cmH O compliance corre2
showing that the ARDS lung can be modeled in one nearly normal
sponds
roughly
to
20
%
open
ventilatable
lung, 50 mL/
region (having dimensions similar to those of a healthy baby) and a
cmH2O to 50 %, and so on. The relationship between the
gasless region

665

Fig. 2 The CT frequency distribution as a function of CT number

compartments distribution of patients with ARDS (black bars) and
normal subjects (gray bars). The diagonal patterned bars indicate
the baby lung in ARDS patients. The zones of hyperinflated,
normally, poorly and not-inflated lung are shown (vertical dashed
lines)

baby lung and gas exchange provided further insight into

flow distribution in ARDS, indicating that the hypoxic
vasoconstriction is still very active in the ARDS lung
[3].

Baby lung and inflammation

Although the specific compliance of the baby lung is
nearly normal, regional quantitative analysis of CT scans
showed that excess tissue mass, at least in severe ARDS,
is present both in non-dependent and in dependent
regions, suggesting that dependent densities primarily
represent atelectasis due to the increased lung weight,
which squeezes the gas out of the most dependent pulmonary units. Therefore, the question arises: if the
parenchyma of the baby lung is mechanically normal, is it
inflamed or simply edematous?
An answer may be provided by positron emission
tomography (PET) which helps to explore the different
properties and functions of the lung tissue by both
imaging and quantitative approaches [4] (Fig. 3). In fact,
PET can assess lung regional vascular permeability by
measuring the plasma escape rate of 68Gallium-transferrin. By this technique, it has been shown that
extravascular lung water is diffusely increased during
ARDS, lobar pneumonia, and acute cardiogenic pulmonary edema. One study [5] showed that in ARDS not

just the non-ventilated regions but also the baby lung

bears one of the hallmarks of tissue inflammation:
increased permeability of the endothelialepithelial barrier. At variance with density and extravascular lung
water, which both increase according to a vertical, gravitational gradient, increased permeability was evenly
distributed throughout the entire ARDS lung and abnormally high in all isogravitational regions [6].
PET also allows investigation of the regional distribution of inflammation, using 18Fluor-deoxy-glucose
(18FDG), an analogue of glucose, which is taken up by cells
in proportion to their metabolic activity. During an
inflammatory process, several cellular types can effectively
uptake 18FDG, including macrophages [7], eosinophils [8]
and alveolar cells [9], with predominant uptake occurring
by neutrophils [10]. In several animal studies, PET with
18FDG has been shown to closely mirror the presence of
inflammatory infiltrate [7] caused by various types of lung
injuries [11], including aggressive ventilation [12].
This tool was applied in ARDS patients, who underwent a combined CT/PET scan. In all patients, the
inflammatory activity of the lungs was increased (sevenfold, on average) in comparison with controls. In this
case, too, the baby lung showed a greater activity than
controls and, in some cases, even a greater activity than
the collapsed, non-aerated lung [13]. At variance from
previous studies [12], 18FDG uptake was not normalized
by the fraction of tissue from the corresponding regions,
since if the increase in tissue fraction was caused by
edema (as likely the case in ARDS), this would lead to an
over-correction of 18FDG signal. However, only tissues
of similar density were directly compared, hence avoiding
the need for density-correction. A subsequent study
investigated the association between mechanical ventilation and inflammatory activity of the baby lung. The
uptake of 18FDG in the normally aerated tissue (the baby
lung) was tightly correlated both with plateau pressure
(with a steep increase for plateau pressure values above
2627 cmH2O) and with the ratio of tidal volume to end
expiratory lung volume of the same regions [14]. These
data suggested a causative role for both stress and strain
in inflaming the ventilated baby lung. A recent CT-PET
study, however, indicated that baby lung inflammation
was primarily a function of ARDS severity. Unlike the
baby lung of mild ARDS, no regions were spared the
inflammatory reaction in severe ARDS [15].

Increasing the baby lung size

Prone position
At the beginning, the baby lung was considered as if it
were an anatomically well-defined entity, with a definite

666

Fig. 3 Representative images of cross-registered computed tomography (at mean airway pressure) and [18F]-fluoro-2-deoxy-Dglucose (18FDG) positron emission tomography from two patients
with acute respiratory distress syndrome. Positron emission tomographic images represent the 18FDG uptake and the color scale

represents radioactivity concentration. a 18FDG distribution parallels that of the opacities detected on CT. b Intense 18FDG uptake
can be observed in normally aerated regions (square 1), while
activity is lower in the dorsal, non-aerated regions of both lungs
(square 2). Reproduced from [13]

spatial location (non-dependent) and with normal

mechanical intrinsic characteristics. However, when the
ARDS lung was studied by CT scan in the prone position
(PP), it appeared that the densities redistributed from the
dorsal to the ventral lung regions, leading to the concept
of the sponge model. Accordingly, the baby lung was
no longer considered an anatomical entity but instead a
functional one, which may quickly change its location
and/or its dimensions with PP and/or application of PEEP
(Fig. 4).

lung volume as well as its topographic distribution. More

uniform distribution of transpulmonary pressure by PP
helps establish and sustain positional recruitment [16, 17]
(Fig. 5). PP relieves cardiac compression of the supporting lung that lies beneath the heart in the supine position
and may improve lymphatic drainage as the heart moves
ventrally to a dependent position [18]. Such changes help
to explain why PP improves shunt and aids resolution of
hydrostatic edema [19, 20].
Yet, recruitment that occurs after turning neither fully
explains proning-related improvements in oxygenation
nor the reduced propensity to ventilator-induced lung
injury (VILI). Establishing more uniform alveolar distension improves ventilation/perfusion ratios of acutely
injured lungs [21]. Proning benefits oxygenation in the
majority of cases and helps ventilation efficiency in a
somewhat lesser proportion of patients [22]. Because
perfusion distribution is only modestly modified by the

Regional mechanics of the baby lung

The anterior chest wall is more flexible than the posterior
one. Therefore, assuming the PP increases total chest wall
elastance, such changes affect trans-pulmonary pressures
and lessen the pressure gradients that determine absolute

667

Fig. 4 Examples of widening the baby lung by prone position (a, b) and by increasing PEEP from 5 cmH2O (c) to 15 cmH2O (d). Note
that recruitment in general proceeds from dorsal to ventral regions in the prone position and from ventral to dorsal by pressure increase

Proning and ventilator-induced lung injury

Fig. 5 The gas:tissue ratio as a function of lung height in supine

(rhombus) prone (circles) positions. The open symbols refer to
normal lungs of 14 patients and the filled symbols to lungs of 20
ARDS patients. The height = 0 refers to the ventral surface in the
supine position and to the dorsal surface in the prone position. The
height scale direction is from nondependent (0) to dependent (100).
Reproduced from Ref. [74]

inversion of position [23], change in the distributional

pattern of ventilation appears to be of greater importance.
Resolving disparities of regional alveolar distension may
also help prevent zonal over-distension and inappropriate
redirection of blood flows from inflated to collapsed units.
The latter phenomenon tends to occur when raising PEEP
and mean airway pressure in the supine position. Right
ventricular afterload may benefit from reduced over-distension, improved oxygenation, and recruitment of
vascular beds [24, 25].

Ventilator-induced lung injury arises from repeated

application of high mechanical forces that either tear
fragile tissue directly or initiate signaling that culminates
in inflammatory change [26]. Stress is augmented at the
interfaces between open and closed (or anatomically noninflatable) tissues, and these stress-focusing junctions (as
well as VILI) prevail in gravitationally dependent zones
[14]. These same units are subjected to surfactant-depleting tidal cycles of airspace opening and closure and to
shearing forces that exceed those experienced by lung
units that remain continuously open. Recruitment that
occurs during proning enlarges the baby lung, reduces the
number of high stress junctions and portends benefit from
repositioning [22]. By reducing the number of interfaces
between open and closed units, as well as by moderating
transpulmonary forces, the regional excursions of
mechanical tension (effective alveolar driving pressures)
are lessened, especially in the dorsal zones. Finally, airway bio-fluids and secretions may directly inhibit
surfactant viability or production, impede the ease of
airspace opening, or predispose to lung infection [27].
Airway drainage, regional mechanics, and vascular filling
are each improved by PP. Perhaps in part for this reason,
hemorrhagic pulmonary edema and inflammation that
result from adverse patterns of ventilation are differentially affected by positioning. In both healthy canine lungs
[28] and those pre-injured by infused oleic acid, proning
may reduce dorsal hemorrhage, edema and inflammation,
whereas nondependent zones are relatively spared in both
positions [28, 29].

668

In addition to attenuating regional transpulmonary

disparities of force, PP confers a secondary benefit simply
by improving the P/F ratio, thereby reducing the need for
potentially iatrogenic interventions to sustain it. Improved
oxygenation by PP may allow reductions of FiO2, mean
airway pressure, and pulmonary vascular resistance,
thereby lowering the risk of injury to mechanically
stressed membranes [30] and/or right ventricular afterload
[31].
Recruitment
The amount of non-aerated and poorly aerated lung
mainly determines the gas exchange impairment observed
in ARDS. The use of PEEP keeps open newly recruited
and previously non-aerated regions, thus enlarging the
baby lung and improving oxygenation. The effects of
PEEP on alveolar recruitment have been assessed using
pressurevolume curves of the respiratory system and CT
scan methods [3234]. Irrespective of how recruitment is
measured, an important concept is that the recruitment
process occurs throughout inspiration, following the trajectory of the pressurevolume relationship of the
respiratory system [33, 35, 36]. Therefore, what can
remain open with PEEP is the tissue that was opened by
the preceding inspiration. In other words, if the previous
end-inspiratory pressure is low, the recruitment obtained
at a given PEEP is less. This is supported by the finding
that de-recruitment that results from decreasing tidal
volume (VT) can be reversed by increasing PEEP [37].
With CT scanning, it has been shown that the amount
of alveolar openingclosing decreases when PEEP
increases [38]. At PEEP levels above 1015 cmH2O and
end-inspiratory plateau airway pressures (Pplat) above 30
cmH2O, the amount of tissue reopening and collapsing
during the tidal cycle was minimal and the VT was
redistributed more homogeneously between dependent
and non-dependent regions.
In a series of studies on ARDS patients, Puybasset
and coworkers performed extensive measurements on
lung CT scans, gas exchange, hemodynamics and
mechanics at zero end-expiratory pressure and PEEP 10
cmH2O [3941]. According to CT scan distribution of
densities, they described three types of patterns: lobar,
diffuse and patchy. Those with a diffuse, as compared to
the lobar pattern, had a significantly lower functional
residual capacity and a significantly higher amount of
non-aerated lung volume. A diffuse versus lobar density
pattern, a lower PaO2/FiO2, and less proportion of aerated lung, identified patients with higher mortality risk.
The decrease in non-aerated lung with PEEP 10 cmH2O
was almost negligible (-82 mL) in patients with lobar
pattern, whereas the highest decrease in non-aerated
lung (-383 mL) was observed in those with a diffuse
pattern.

The overall effects of PEEP on recruitability, however, are complex. The percentage of potentially
recruitable lung, as analyzed with CT scans performed up
to 45 cmH2O airway pressure, was highly variable in
acute lung injury/ARDS patients [42]. About 24 % of the
lung could not be recruited even at 45 cmH2O, and lung
recruitment occurring from PEEP 515 cmH2O correlated
well with the percentage of potentially recruitable lung.
Interestingly, patients with a high percentage of potentially recruitable lung had higher mortality rates than
those with a low percentage. As recruitability increased
with severity, it follows that the smaller the baby lung at
low pressure, the greater would be its relative increase
when PEEP is increased. A further analysis by Caironi
and coworkers [43], showed that, in patients with a higher
percentage of potentially recruitable lung, raising PEEP
from 5 to 15 markedly decreased the amount of opening
closing lung tissue, but PEEP did not produce any effect
in patients with a lower percentage of potentially
recruitable lung. Analysis of the association between
mortality and determinants of VILI showed that the
amount of openingclosing was independently associated
with an increased risk of death. A recent study [44] has
shown that, among different bedside PEEP selection
methods in ARDS patients, the one based on oxygenation
criteria was most closely related to lung recruitability.
Taken together, these data [4244] suggest high PEEP
levels should be used in more severe ARDS but not in
patients with a lower percentage of potentially
recruitable lung. In other words, the smaller the baby lung
at low pressure the greater the PEEP to be applied.
Recently, Cressoni et al. [45] showed that the greater
the ARDS severity, the greater the lung inhomogeneity.
Such inhomogeneities were mainly distributed at the
interface between lung regions with high and normal CT
density, i.e. at the boundary zones of the baby lung,
which were more numerous in non-survivors than in
survivors and were always inflamed, as shown by PET
[15]. The authors proposed that lung inhomogeneity acts
as a stress raiser, and they calculated that these regions are
exposed to a stress which almost doubles the transpulmonary pressure applied. Such a mechanism (stress
raising) can further magnify VILI. Interestingly, the
extent of inhomogeneity was associated with the fraction
of poorly aerated lung tissue, and it decreased when PEEP
was increased.
Are there clinical data to suggest which PEEP level is
most appropriate in ARDS? In the ExPress study [46], the
use of low VT with high PEEP (about 15 cmH2O, individually titrated to reach a Pplat of 2830 cmH2O) tended
to increase mortality in acute lung injury patients when
compared to low VT and moderate PEEP. Conversely, the
low VT/high PEEP strategy decreased mortality in sicker
ARDS patients. A secondary post hoc analysis of randomized PEEP trials further supports the selective use of
high PEEP levels in severe ARDS patients, i.e. those with

669

smaller baby lungs [47]. Our understanding of the effects

of PEEP in the baby lung is maturing. The new clinical
challenge is to determine whether a PEEP titration strategy based on sound physiological and morphological
principles, and which can be easily used at the bedside
(using measurements such as dead space or driving
pressures), improves outcomes in ARDS.

Baby lung and mechanical ventilation

Tidal volume and plateau pressure
In clinical practice, tidal volume is scaled to patient ideal
body weight (IBW), predicted from the patient height
(VT/IBW) to avoid excessive strain of the lung parenchyma. Relatively high tidal volumes, quantified as
12 mL/kg IBW or greater, cause un-physiological strain
in the size-reduced ARDS lung. In turn, excessive strain
causes, through mechanical transduction, increased local
inflammation and inflammatory cytokines which likely
contribute to increased mortality. Halving the harmful
tidal volume may decrease mortality but predisposes to
CO2 retention (permissive hypercapnia) which, when
moderate, is generally well tolerated and possible beneficial. Several clinical studies have analyzed the effects of
lower versus higher values of VT/IBW. Among these
outcome studies testing different tidal volumes, only the
ARDS Network study, which compared the two extreme
values (6 vs. 12 mL/kg) in 861 patients, showed a significant mortality reduction in the lower VT group (31 vs.
40 %) [48]. Although other studies did not find any significant mortality reduction [4951] when testing VT
values intermediate within the 612 mL/kg interval, low
VT ventilation (6 ml/k IBW ventilation) has been widely
accepted by the scientific community. Over-distension,
however, has been described in the non-dependent lung
regions even at 6 ml/kg IBW [52]. Although the ideal (or
predicted) body weight was introduced as a better surrogate than measured weight to adjust for variations in lung
size, it is evident that this approach does not perform
optimally well in ARDS. In a man with an ideal body
weight of 70 kg, the aeratable lung volume, i.e. the baby
lung, may range from 200 to 300 ml to more than
1000 ml, depending on the ARDS severity. Referring to
the gas volume of the baby lung instead of to the body
weight is more physiologically adequate as it better
reflects its distortion (strain) during ventilation. In fact,
strain is defined as the ratio between tidal volume and the
baseline gas volume of the baby lung. In the example
above, the estimated strain induced by a tidal volume of
6 ml/kg IBW would range between 2.1 and 0.42values
found in animal studies to be lethal (i.e. leading to death)
and innocent (without any harm), respectively. Therefore,
a safer mechanical ventilation strategy should consider

the size of the baby lung instead of body weight [53].

More recently, a post hoc analysis of 3562 patients with
ARDS enrolled in nine previously reported randomized
trials [54], compared the relative predictive power of tidal
volume normalized to estimated lung compliance (driving
pressure) with tidal volume normalized to ideal body
weight. The former index performed considerably better,
suggesting that compliancean indicator of baby lung
sizeis a better surrogate than ideal body weight when
tailoring tidal volume to prevent excessive strain.
The same line of reasoning may be applied when
considering the stress, i.e. the pressure, which develops
within lung structures to counteract the applied transpulmonary pressure. Therefore the stress equals the
transpulmonary pressure (with opposite sign). The widely
accepted surrogate for stress is the airway plateau pressure, and 30 cmH2O is the suggested limit [55]. A simple
analysis of the relationship of transpulmonary pressure
(PL) and airway pressure (PAW) shows how this suggestion is questionable. In fact, the same PAW is associated
with a wide range of PL due to different ratios of chest
wall elastance (EW) to respiratory system elastance (ERS)
PL PAW 

EW
ERS

A post hoc analysis by the ARDS network could not

identify a safe upper limit for plateau pressures in patients
with ALI/ARDS, as values even lower than 30 cmH2O
might cause lung damage [56]. These data indicate that at
30 cmH2O the baby lung may be very close to its total
lung capacity or very far from it. Depending on chest wall
elastance, transpulmonary pressure associated with 30
cmH2O can be estimated to vary between 28 and 8
cmH2O [53]. In animal studies, these levels are lethal or
innocent, respectively [57].
Baby lung and spontaneous breathing
Although awareness of the baby lung concept has
encouraged significant improvement in ventilator management, the same reasoning has not always been
followed when the patient makes breathing efforts, as
during noninvasive ventilatory support and when allowing some spontaneous breathing activity during the early
phase of ARDS.
In theory, baby lung size should be the same at a given
transpulmonary pressure, whether it is generated by a
positive pressure, by a negative pressure (and therefore
the respiratory muscles) or by a combination of the two.
The validity of this principle was illustrated in an early
animal model of VILI [58]. During spontaneous breathing, however, negative pleural pressure swings will have
different vascular effects than during controlled
mechanical ventilation, resulting in higher filling

670

pressures of the heart and in the pulmonary circulation

[59]. This vascular congestion may increase the risk of
VILI [60, 61]. In addition, the measurement of esophageal
pressure may poorly reflect the distribution of regional
pleural and transpulmonary pressures. Under the action of
the diaphragm and of other accessory muscles, the
regional pleural pressures may have a wider distribution
than during controlled mechanical ventilation, where the
gradient of pleural pressure is mostly dictated by gravity.
Local variations of distending pressure may help explain
the observation of pendelluft (i.e., regional redistribution
of ventilation during the tidal cycle), among injured lung
regions during spontaneous breathing [62]. In such cases,
the risk of VILI may be poorly reflected by the global
transpulmonary pressure.
Experimental and clinical data
Sustained hyperventilation induced by severe acidosis may
lead to acute lung injury in animals [63]. In experimental
models, however, allowing spontaneous breathing seems to
have different consequences, depending on the severity of
lung injury [64]. In the case of severe lung injury, spontaneous breathing appears to worsen damage while the
opposite may happen in those with mild injury. These differences may reflect an increase in transpulmonary pressure
and tidal volume during spontaneous ventilation, associated with high regional distending pressures and increases
of trans-vascular pressure. A series of studies conducted in
patients, confirmed by a multicenter trial, strongly suggested that the systematic administration of neuromuscular
blockers can reduce biomarkers of inflammation and
improve survival in patients with ARDS [65, 66]. Neuromuscular blockade was also the first treatment to show a
significant reduction in the rate of pneumothorax (11.7 vs.
4.0 %). Of note, even the seminal study on low tidal volume
did not show any reduction of barotrauma [48]. These
results seem to have been determined primarily by data
from patients with PaO2/FiO2 at or below 120 mmHg [65].
Although these results are not fully understood, they suggest a possible negative effect of spontaneous breathing on
local distending pressures, as discussed above, by high
ventilatory drive-caused asynchronies such as breath
stacking and double cycling, or by reverse triggering. [67,
68]. In this situation, clinicians should carefully monitor the
results of patientventilator synchronization in terms of the
resulting tidal volume and transpulmonary pressure. Clinicians must be aware of the physiological differences
between volume-controlled and pressure controlled ventilation on both trans-pulmonary pressure and patient
comfort [69]. The use of non- synchronized pressure-targeted modes in this situation may help to maintain some
spontaneous breathing activity with minimal risks, offering
an interesting compromise [70].

Noninvasive ventilatory support

In non-intubated patients, gauging the severity of lung
injury presents problems because respiratory mechanics
are difficult to assess. Noninvasive ventilation has been
frequently attempted in lung-injured patients as a way to
avoid intubation, with various degrees of success [71, 72].
Recently, another technique of noninvasive ventilatory
support in the form of high-flow heated and humidified
oxygen therapy has been tested in patients with acute
hypoxemic respiratory failure mostly resulting from severe infectious pneumonia [73]. Patients with PaO2/FiO2 at
or below 200 mmHg were less likely to need intubation
than those treated by conventional masks. Overall,
patients treated by high-flow nasal oxygen had a lower
hospital and 90-day mortality. Such surprising results
clearly need confirmation. However, one possibility to
explain the benefit in survival with this simple and welltolerated technique may be a reduction in ventilatory
needs due to a washout of anatomic dead space. Although
not clearly demonstrated, it is conceivable that a reduction
in tidal volume and/or in minute ventilation imposed on
the baby lung (due to dead space wash-out or improved
comfort) could explain this observed decrease in
mortality.

Conclusions
The size of the baby lung determines tissue compliance
and directly dictates the mechanical properties of the
ARDS lung. For a given tidal volume, therefore, stress
and strain relate to baby lung size. Physical characteristics
such as mechanical homogeneity and dimension of the
baby lung may be deeply affected by PP and PEEP. The
positive effects of these two maneuvers appear inversely
related to the baby lung size. Although less well documented, these same rules are likely to apply when
spontaneous breathing efforts are made. The baby lung
concept may help to understand and implement safe
mechanical or spontaneous ventilation during the different stages of ARDS.
Acknowledgments We thank Prof. Giacomo Bellani (Dipartimento di Medicina e Chirurgia, Universita` degli Studi di Milano
Bicocca, Milan, Italy) and Eleonora Carlesso (Dipartimento di
Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione
IRCCS Ca Granda-Ospedale Maggiore Policlinico, Universita`
degli Studi di Milano, Milan, Italy) for their invaluable support in
the preparation of this manuscript.

Compliance with ethical standards

Conflicts of interest

None.

671

References
1. Gattinoni L, Mascheroni D, Torresin A
et al (1986) Morphological response to
positive end expiratory pressure in
acute respiratory failure. Computerized
tomography study. Intensive Care Med
12:137142
2. Gattinoni L, Pesenti A, Avalli L et al
(1987) Pressure-volume curve of total
respiratory system in acute respiratory
failure. Computed tomographic scan
study. Am Rev Respir Dis 136:730736
3. Cressoni M, Caironi P, Polli F et al
(2008) Anatomical and functional
intrapulmonary shunt in acute
respiratory distress syndrome. Crit Care
Med 36:669675
4. Bellani G, Amigoni M, Pesenti A
(2011) Positron emission tomography
in ARDS: a new look at an old
syndrome. Minerva Anestesiol
77:439447
5. Kaplan JD, Calandrino FS, Schuster DP
(1991) A positron emission
tomographic comparison of pulmonary
vascular permeability during the adult
respiratory distress syndrome and
pneumonia. Am Rev Respir Dis
143:150154
6. Sandiford P, Province MA, Schuster DP
(1995) Distribution of regional density
and vascular permeability in the adult
respiratory distress syndrome. Am J
Respir Crit Care Med 151:737742
7. Zambelli V, Di Grigoli G, Scanziani M
et al (2012) Time course of metabolic
activity and cellular infiltration in a
murine model of acid-induced lung
injury. Intensive Care Med 38:694701
8. Harris RS, Venegas JG,
Wongviriyawong C et al (2011) 18FFDG uptake rate is a biomarker of
eosinophilic inflammation and airway
response in asthma. J Nucl Med
52:17131720
9. Saha D, Takahashi K, de Prost N et al
(2013) Micro-autoradiographic
assessment of cell types contributing to
2-deoxy-2-[(18)F]fluoro-D-glucose
uptake during ventilator-induced and
endotoxemic lung injury. Mol Imaging
Biol 15:1927
10. Musch G (2011) Positron emission
tomography: a tool for better
understanding of ventilator-induced and
acute lung injury. Curr Opin Crit Care
17:712
11. de Prost N, Feng Y, Wellman T et al
(2014) 18F-FDG kinetics parameters
depend on the mechanism of injury in
early experimental acute respiratory
distress syndrome. J Nucl Med
55:18711877

12. Musch G, Venegas JG, Bellani G et al

(2007) Regional gas exchange and
cellular metabolic activity in ventilatorinduced lung injury. Anesthesiology
106:723735
13. Bellani G, Messa C, Guerra L et al
(2009) Lungs of patients with acute
respiratory distress syndrome show
diffuse inflammation in normally
aerated regions: a [18F]-fluoro-2deoxy-D-glucose PET/CT study. Crit
Care Med 37:22162222
14. Bellani G, Guerra L, Musch G et al
(2011) Lung regional metabolic activity
and gas volume changes induced by
tidal ventilation in patients with acute
lung injury. Am J Respir Crit Care Med
183:11931199
15. Cressoni M, Chiumello D, Chiurazzi C
et al (2016) Lung inhomogeneities,
inflation and [18F]2-fluoro-2-deoxy-Dglucose uptake rate in acute respiratory
distress syndrome. Eur Respir J
47(1):233242
16. Cakar N, der Kloot TV, Youngblood M
et al (2000) Oxygenation response to a
recruitment maneuver during supine
and prone positions in an oleic acidinduced lung injury model. Am J Respir
Crit Care Med 161:19491956
17. Guerin C, Baboi L, Richard JC (2014)
Mechanisms of the effects of prone
positioning in acute respiratory distress
syndrome. Intensive Care Med
40:16341642
18. Albert RK, Hubmayr RD (2000) The
prone position eliminates compression
of the lungs by the heart. Am J Respir
Crit Care Med 161:16601665
19. Chatte G, Sab JM, Dubois JM et al
(1997) Prone position in mechanically
ventilated patients with severe acute
respiratory failure. Am J Respir Crit
Care Med 155:473478
20. Nakos G, Tsangaris I, Kostanti E et al
(2000) Effect of the prone position on
patients with hydrostatic pulmonary
edema compared with patients with
acute respiratory distress syndrome and
pulmonary fibrosis. Am J Respir Crit
Care Med 161:360368
21. Lamm WJ, Graham MM, Albert RK
(1994) Mechanism by which the prone
position improves oxygenation in acute
lung injury. Am J Respir Crit Care Med
150:184193
22. Gattinoni L, Vagginelli F, Carlesso E
et al (2003) Decrease in PaCO2 with
prone position is predictive of improved
outcome in acute respiratory distress
syndrome. Crit Care Med
31:27272733

23. Wiener CM, Kirk W (1985) Albert RK

(1990) Prone position reverses
gravitational distribution of perfusion in
dog lungs with oleic acid-induced
injury. J Appl Physiol Bethesda Md
68:13861392
24. Jozwiak M, Teboul J-L, Anguel N et al
(2013) Beneficial hemodynamic effects
of prone positioning in patients with
acute respiratory distress syndrome. Am
J Respir Crit Care Med 188:14281433
25. Richard J-C, Bregeon F, Costes N et al
(2008) Effects of prone position and
positive end-expiratory pressure on
lung perfusion and ventilation. Crit
Care Med 36:23732380
26. Dreyfuss D, Saumon G (1998)
Ventilator-induced lung injury: lessons
from experimental studies. Am J Respir
Crit Care Med 157:294323
27. Marini JJ, Gattinoni L (2008)
Propagation prevention: a
complementary mechanism for lung
protective ventilation in acute
respiratory distress syndrome. Crit Care
Med 36:32523258
28. Broccard AF, Shapiro RS, Schmitz LL
et al (1997) Influence of prone position
on the extent and distribution of lung
injury in a high tidal volume oleic acid
model of acute respiratory distress
syndrome. Crit Care Med 25:1627
29. Broccard A, Shapiro RS, Schmitz LL
et al (2000) Prone positioning
attenuates and redistributes ventilatorinduced lung injury in dogs. Crit Care
Med 28:295303
30. Marini JJ, Hotchkiss JR, Broccard AF
(2003) Bench-to-bedside review:
microvascular and airspace linkage in
ventilator-induced lung injury. Crit
Care Lond Engl 7:435444
31. Repesse X, Charron C, Vieillard-Baron
A (2015) Acute cor pulmonale in
ARDS: rationale for protecting the right
ventricle. Chest 147:259265
32. Gattinoni L, Pesenti A (2005) The
concept of baby lung. Intensive Care
Med 31:776784
33. Gattinoni L, Caironi P, Pelosi P,
Goodman LR (2001) What has
computed tomography taught us about
the acute respiratory distress syndrome?
Am J Respir Crit Care Med
164:17011711
34. Malbouisson LM, Muller JC,
Constantin JM et al (2001) Computed
tomography assessment of positive endexpiratory pressure-induced alveolar
recruitment in patients with acute
respiratory distress syndrome. Am J
Respir Crit Care Med 163:14441450

672

35. Jonson B, Richard JC, Straus C et al

(1999) Pressure-volume curves and
compliance in acute lung injury:
evidence of recruitment above the lower
inflection point. Am J Respir Crit Care
Med 159:11721178
36. Crotti S, Mascheroni D, Caironi P et al
(2001) Recruitment and derecruitment
during acute respiratory failure: a
clinical study. Am J Respir Crit Care
Med 164:131140
37. Richard JC, Maggiore SM, Jonson B
et al (2001) Influence of tidal volume
on alveolar recruitment. Respective role
of PEEP and a recruitment maneuver.
Am J Respir Crit Care Med
163:16091613
38. Gattinoni L, Pelosi P, Crotti S, Valenza
F (1995) Effects of positive endexpiratory pressure on regional
distribution of tidal volume and
recruitment in adult respiratory distress
syndrome. Am J Respir Crit Care Med
151:18071814
39. Puybasset L, Cluzel P, Gusman P et al
(2000) Regional distribution of gas and
tissue in acute respiratory distress
syndrome. I. Consequences for lung
morphology. CT Scan ARDS Study
Group. Intensive Care Med 26:857869
40. Rouby JJ, Puybasset L, Cluzel P et al
(2000) Regional distribution of gas and
tissue in acute respiratory distress
syndrome. II. Physiological correlations
and definition of an ARDS Severity
Score. CT Scan ARDS Study Group.
Intensive Care Med 26:10461056
41. Puybasset L, Gusman P, Muller JC et al
(2000) Regional distribution of gas and
tissue in acute respiratory distress
syndrome. III. Consequences for the
effects of positive end-expiratory
pressure. CT Scan ARDS Study Group.
Adult respiratory distress syndrome.
Intensive Care Med 26:12151227
42. Gattinoni L, Caironi P, Cressoni M et al
(2006) Lung recruitment in patients
with the acute respiratory distress
syndrome. N Engl J Med
354:17751786
43. Caironi P, Cressoni M, Chiumello D
et al (2010) Lung opening and closing
during ventilation of acute respiratory
distress syndrome. Am J Respir Crit
Care Med 181:578586
44. Chiumello D, Cressoni M, Carlesso E
et al (2014) Bedside selection of
positive end-expiratory pressure in
mild, moderate, and severe acute
respiratory distress syndrome. Crit Care
Med 42:252264
45. Cressoni M, Cadringher P, Chiurazzi C
et al (2014) Lung inhomogeneity in
patients with acute respiratory distress
syndrome. Am J Respir Crit Care Med
189:149158

46. Mercat A, Richard JCM, Vielle B et al

(2008) Positive end-expiratory pressure
setting in adults with acute lung injury
and acute respiratory distress
syndromeA randomized controlled
trial. JAMA 299:646655
47. Goligher EC, Kavanagh BP, Rubenfeld
GD et al (2014) Oxygenation response
to positive end-expiratory pressure
predicts mortality in acute respiratory
distress syndrome. A secondary
analysis of the LOVS and ExPress
trials. Am J Respir Crit Care Med
190:7076
48. The Acute Respiratory Distress
Syndrome Network (2000) Ventilation
with lower tidal volumes as compared
with traditional tidal volumes for acute
lung injury and the acute respiratory
distress syndrome. N Engl J Med
342(18):13011308
49. Brochard L, Roudot-Thoraval F,
Roupie E et al (1998) Tidal volume
reduction for prevention of ventilatorinduced lung injury in acute respiratory
distress syndrome. The Multicenter
Trail Group on Tidal Volume reduction
in ARDS. Am J Respir Crit Care Med
158:18311838
50. Brower RG, Lanken PN, MacIntyre N
et al (2004) Higher versus lower
positive end-expiratory pressures in
patients with the acute respiratory
distress syndrome. N Engl J Med
351:327336
51. Stewart TE, Meade MO, Cook DJ et al
(1998) Evaluation of a ventilation
strategy to prevent barotrauma in
patients at high risk for acute
respiratory distress syndrome. Pressureand Volume-Limited Ventilation
Strategy Group. N Engl J Med
338:355361
52. Terragni PP, Rosboch G, Tealdi A et al
(2007) Tidal hyperinflation during low
tidal volume ventilation in acute
respiratory distress syndrome. Am J
Respir Crit Care Med 175:160166
53. Chiumello D, Carlesso E, Cadringher P
et al (2008) Lung stress and strain
during mechanical ventilation for acute
respiratory distress syndrome. Am J
Respir Crit Care Med 178:346355
54. Amato MBP, Meade MO, Slutsky AS
et al (2015) Driving pressure and
survival in the acute respiratory distress
syndrome. N Engl J Med 372:747755
55. Tobin MJ (2000) Culmination of an era
in research on the acute respiratory
distress syndrome. N Engl J Med
342:13601361
56. Hager DN, Krishnan JA, Hayden DL,
Brower RG (2005) Tidal volume
reduction in patients with acute lung
injury when plateau pressures are not
high. Am J Respir Crit Care Med
172:12411245

57. Protti A, Andreis DT, Monti M et al

(2013) Lung stress and strain during
mechanical ventilation: any difference
between statics and dynamics? Crit
Care Med 41:10461055
58. Dreyfuss D, Soler P, Basset G, Saumon
G (1988) High inflation pressure
pulmonary edema. Respective effects of
high airway pressure, high tidal volume,
and positive end-expiratory pressure.
Am Rev Respir Dis 137:11591164
59. Magder S, Verscheure S (2014) Proper
reading of pulmonary artery vascular
pressure tracings. Am J Respir Crit
Care Med 190:11961198
60. Hotchkiss JR, Blanch L, Naveira A et al
(2001) Relative roles of vascular and
airspace pressures in ventilator-induced
lung injury. Crit Care Med
29:15931598
61. Broccard AF, Hotchkiss JR, Kuwayama
N et al (1998) Consequences of
vascular flow on lung injury induced by
mechanical ventilation. Am J Respir
Crit Care Med 157:19351942
62. Yoshida T, Torsani V, Gomes S et al
(2013) Spontaneous effort causes occult
pendelluft during mechanical
ventilation. Am J Respir Crit Care Med
188:14201427
63. Mascheroni D, Kolobow T, Fumagalli
R et al (1988) Acute respiratory failure
following pharmacologically induced
hyperventilation: an experimental
animal study. Intensive Care Med
15:814
64. Yoshida T, Uchiyama A, Matsuura N
et al (2012) Spontaneous breathing
during lung-protective ventilation in an
experimental acute lung injury model:
high transpulmonary pressure
associated with strong spontaneous
breathing effort may worsen lung
injury. Crit Care Med 40:15781585
65. Papazian L, Forel JM, Gacouin A et al
(2010) Neuromuscular blockers in early
acute respiratory distress syndrome.
N Engl J Med 363:11071116
66. Forel J-M, Roch A, Marin V et al
(2006) Neuromuscular blocking agents
decrease inflammatory response in
patients presenting with acute
respiratory distress syndrome. Crit Care
Med 34:27492757
67. Slutsky AS (2010) Neuromuscular
blocking agents in ARDS. N Engl J
Med 363:11761180
68. Akoumianaki E, Lyazidi A, Rey N et al
(2013) Mechanical ventilation-induced
reverse-triggered breaths: a frequently
unrecognized form of neuromechanical
coupling. Chest 143:927938
69. Rittayamai N, Katsios CM, Beloncle F
et al (2015) Pressure-controlled vs
volume-controlled ventilation in acute
respiratory failure: a physiology-based
narrative and systematic review. Chest
148:340355

673

70. Richard JCM, Lyazidi A, Akoumianaki 72. Brochard L, Lefebvre J-C, Cordioli RL 74. Gattinoni L, Taccone P, Mascheroni D
et al (2013) Prone positioning in acute
et al (2014) Noninvasive ventilation for
E et al (2013) Potentially harmful
respiratory failure. In: Tobin MJ (ed)
patients with hypoxemic acute
effects of inspiratory synchronization
Principles and practice of mechanical
respiratory failure. Semin Respir Crit
during pressure preset ventilation.
ventilation, 3rd edn. McGraw Hill, New
Care Med 35:492500
Intensive Care Med 39:20032010
York, pp 11691181
73. Frat J-P, Thille AW, Mercat A et al
71. Antonelli M, Conti G, Rocco M et al
(2015) High-flow oxygen through nasal
(1998) A comparison of noninvasive
cannula in acute hypoxemic respiratory
positive-pressure ventilation and
failure. N Engl J Med 372:21852196
conventional mechanical ventilation in
patients with acute respiratory failure.
N Engl J Med 339:429435