Conventional protective ventilation with elevated mechanical power: Migration to safer values with small ventilatory adjustments

Claudio Luciano Franck, Bernardo Gomes Doelinger, Ester Lopes Correa Dos Santos

Abstract

Background

Mechanical power (MP) integrates multiple ventilatory variables into a single measure of the energy delivered to the respiratory system and has been associated with ventilator-induced lung injury and adverse outcomes. However, it remains unclear whether ventilatory observations meeting conventional protective criteria also exhibit low MP and whether small ventilatory adjustments can meaningfully reduce MP in severely burned patients undergoing pressure-controlled ventilation (PCV).

Methods

This interventional repeated-measures study with randomized sequence of ventilatory adjustment protocols included adult burn patients receiving PCV in an intensive care unit. A total of 123 paired ventilatory observations were screened. Three reductive ventilatory strategies were assessed: reduction of inspiratory pressure variation by 2 cmH₂O (ΔPinsp), reduction of respiratory rate by 2 breaths/min (RR), and combined reductions of 1 cmH₂O and 1 breath/min (RR–ΔPinsp). Thirty-nine ventilatory observations meeting predefined protective tidal-volume and pressure criteria constituted the analytical sample. MP was calculated using the simplified Becher equation. Clinical, arterial blood gases, and ventilatory effects were evaluated at baseline and one hour after the interventions, as well as migration between MP categories (<1 8 and ≥ 18 J/min).

Results

Oxygenation remained stable, with no significant changes in PaO₂, SpO₂, or PaO₂/FiO₂. PaCO₂ increased modestly and arterial pH decreased slightly, but both remained within physiological limits. No desaturation, clinically relevant acidosis, hemodynamic instability, or ventilatory asynchrony was observed. Among the 39 ventilatory observations, 17 (43.6%) had MP ≥ 18 J/min at baseline. MP decreased significantly from 17.39 to 15.02 J/min overall (P < 0.001). The greatest reduction was observed in the ΔPinsp group (3.00 J/min), followed by RR–ΔPinsp (2.34 J/min) and RR (1.78 J/min), with significant differences among strategies. Ventilatory observations with MP <18 J/min increased from 22/39 (56.4%) to 34/39 (87.2%), whereas those with MP ≥ 18 J/min decreased from 17/39 (43.6%) to 5/39 (12.8%) (P < 0.001).

Conclusions

A substantial proportion of ventilatory observations meeting conventional protective criteria still exhibited elevated MP. Small ventilatory adjustments during protective PCV were associated with significant reductions in calculated MP and migration toward values below 18 J/min without compromising short-term arterial blood gases or clinical stability. Reduction in inspiratory pressure variation produced the greatest effect on MP.     

Keywords: Mechanical Power, Burns; Mechanical Ventilation; Pressure-Controlled Ventilation; Ventilator-Induced Lung Injury.

References

1. Vivó C, Galeiras R, Del Caz MDP. Initial evaluation and management of the critical burn patient. Med Intensiva 2016; 40(1):49-59. https://doi.org/10.1016/j.medin.2015.11.010 PMid:26724246

2. von Düring S, Parhar KKS, Adhikari NKJ, et al. Understanding ventilator-induced lung injury: the role of mechanical power. J Crit Care 2025; 85:154902. https://doi.org/10.1016/j.jcrc.2024.154902 PMid:39241350

3. Vasques F, Duscio E, Pasticci I, et al. Is the mechanical power the final word on ventilator-induced lung injury? We are not sure. Ann Transl Med 2018; 6(19):395. https://doi.org/10.21037/atm.2018.08.17 PMid:30460269 PMCid:PMC6212351

4. Fan E, Del Sorbo L, Goligher EC, et al. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical practice guideline: Mechanical ventilation in adult patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2017; 195(9):1253-1263. https://doi.org/10.1164/rccm.201703-0548ST PMid:28459336

5. Fajardo-Campoverdi A, Ibarra-Estrada M, González-Castro A, et al. High rate-trauma: the new world order? Med Intensiva (Engl Ed) 2024; 48(8):490-492. https://doi.org/10.1016/j.medin.2024.03.002 PMid:38594111

6. Gattinoni L, Collino F, Camporota L. Mechanical power: meaning, uses and limitations. Intensive Care Med 2023; 49:465-467. https://doi.org/10.1007/s00134-023-06991-3 PMid:36884050 PMCid:PMC10119242

7. Simonete A, Alberti da Silva N, Franck CL. Analysis of mechanical power during pressure-controlled ventilation in patients with severe burns. J Mech Vent 2023; 4(2):66-71. https://doi.org/10.53097/JMV.10076

8. Coppola S, Caccioppola A, Froio S, et al. Effect of mechanical power on intensive care mortality in ARDS patients. Crit Care 2020; 24(1):246. https://doi.org/10.1186/s13054-020-02963-x PMid:32448389 PMCid:PMC7245621

9. Manrique S, Ruiz-Botella M, Murillo N, et al. Impact of mechanical power on ICU mortality in ventilated critically ill patients: a retrospective study with continuous real-life data. Eur J Med Res 2024; 29(1):491. https://doi.org/10.1186/s40001-024-02082-1 PMid:39375738 PMCid:PMC11457382

10. Marini JJ, Rocco PRM, Gattinoni L. Static and dynamic contributors to ventilator-induced lung injury in clinical practice: pressure, energy, and power. Am J Respir Crit Care Med 2020; 201(7):767-774. https://doi.org/10.1164/rccm.201908-1545CI PMid:31665612 PMCid:PMC7124710

11. Chi Y, He HW, Long Y. Progress of mechanical power in the intensive care unit. Chin Med J (Engl) 2020; 133(18):2197-2204. https://doi.org/10.1097/CM9.0000000000001018 PMid:32842009 PMCid:PMC7508452

12. Harder J, Molter J, Nugent K. The association of ventilator mechanical power with weaning outcomes in intensive care unit patients: a narrative review. J Thorac Dis 2025; 17(1):487-495. https://doi.org/10.21037/jtd-24-1381 PMid:39975757 PMCid:PMC11833598

13. Fabry B. How to minimize mechanical power during controlled mechanical ventilation. Intensive Care Med Exp 2024; 12:114. https://doi.org/10.1186/s40635-024-00699-4 PMid:39652195 PMCid:PMC11628461

14. Buiteman-Kruizinga LA, van Meenen DMP, Serpa Neto A, et al. Association of ventilation volumes, pressures and rates with the mechanical power of ventilation in patients without acute respiratory distress syndrome: exploring the impact of rate reduction. Anaesthesia 2025; 80(5):533-542. https://doi.org/10.1111/anae.16537 PMid:39938476 PMCid:PMC11987796

15. Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002; 166(10):1338-1344. https://doi.org/10.1164/rccm.2107138 PMid:12421743

16. Becher T, van der Staay M, Schädler D, et al. Calculation of mechanical power for pressure-controlled ventilation. Intensive Care Med 2019; 45:1321-1323. https://doi.org/10.1007/s00134-019-05636-8 PMid:31101961

17. Fioccola A, Pozzi T, Fratti I, et al. Impact of mechanical power and positive end-expiratory pressure on oxygen and carbon dioxide variables in female piglets. Physiol Rep 2024; 12(4):e15954. https://doi.org/10.14814/phy2.15954 PMid:38366303 PMCid:PMC10873162

18. Semler MW, Casey JD, Lloyd BD, et al. Oxygen-saturation targets for critically ill adults receiving mechanical ventilation. N Engl J Med 2022; 387(19):1759-1769. https://doi.org/10.1056/NEJMoa2208415 PMid:36278971

19. Battaglini D, Pelosi P, Robba C. Ten rules for optimizing ventilatory settings and targets in post-cardiac arrest patients. Crit Care 2022; 26(1):390. https://doi.org/10.1186/s13054-022-04268-7 PMid:36527126 PMCid:PMC9758928

20. Robba C, Siwicka-Gieroba D, Sikter A, et al. Pathophysiology and clinical consequences of arterial blood gases and pH after cardiac arrest. Intensive Care Med Exp 2020; 8:19. https://doi.org/10.1186/s40635-020-00307-1 PMid:33336311 PMCid:PMC7746422

21. Sim JK, Lee SM, Kang HK, et al. Association between mechanical power and intensive care unit mortality in Korean patients under pressure-controlled ventilation. Acute Crit Care 2024; 39(1):91-99. https://doi.org/10.4266/acc.2023.00871 PMid:38303581 PMCid:PMC11002610

22. Kallet RH, Lipnick MS. Pressure control surrogate formula for estimating mechanical power in ARDS is associated with mortality. Respir Care 2025; 70(4):427-433. https://doi.org/10.4187/respcare.12269 PMid:39242173

23. El-Khatib MF, Zeinelddine SM, HajAli TH, et al. Effect of ventilator settings on mechanical power during simulated mechanical ventilation of patients with ARDS. Respir Care 2024; 69(4):449-456. https://doi.org/10.4187/respcare.11470 PMid:38538014 PMCid:PMC11108119