Rethinking ARDS classification: oxygenation impairment fails to predict VILI risk

Purpose: The selection and intensity of respiratory support for ARDS are guided by PaO₂/FiO₂. However, ventilator-induced lung injury (VILI) is linked to respiratory mechanics and ventilator settings. We explored whether the VILI risk is related to ARDS severity based on oxygenation.

Methods: We analysed data on 228 ARDS subjects with PaO₂/FiO₂ < 200 mmHg, categorized into three severity groups: one based on PaO₂/FiO₂ ratio, and the others based on tertiles of predictors of VILI: mechanical power ratio (MPR) and driving pressure (DP). In each group of oxygenation-based ARDS severity and MPR and DP tertiles, we measured CT anatomy, gas exchange, respiratory mechanics, VILI prerequisites (lung elastance and lung gas volume), and VILI determinants (tidal volume, PEEP, airway pressures).

Results: Predictors of VILI, such as MPR and DP, were similar across ARDS severity groups based on PaO₂/FiO₂ ratio, while oxygenation remained comparable across different levels of VILI risk defined by MPR and DP. Oxygenation impairment was associated with increased lung weight, recruitability, and reduced well-inflated tissue. In contrast, MPR and DP tertiles affected variables associated with the baby lung size, such as lung gas volume and well-inflated tissue. Mechanical ventilation intensity increased progressively across MPR and DP tertiles, but remained similar across PaO₂/FiO₂ severity groups.

Conclusions: ARDS severity based on oxygenation impairment does not reflect the prerequisites and determinants of VILI. This should prompt a reconsideration of recommending respiratory support based on oxygenation impairment, rather than VILI determinants.