In respiratory failure, there is regional variability in oxygenation (and perfusion)- imaging can be used to monitor this. Point of care ultrasound for instance ncbi.nlm.nih.gov/pmc/articles/P…
Electrical Impedance tomography can monitor regional changes as well ncbi.nlm.nih.gov/pubmed/25843526
Oesophageal manometry can help us monitor transpulmonary pressure nejm.org/doi/full/10.10… – however is only used in about 1% of ARDS patients according to the LUNG-SAFE study jamanetwork.com/journals/jama/…
Respiratory muscle functioning can be done using the NAVA device journals.sagepub.com/doi/pdf/10.117… – this may end up being key to keeping intrapleural driving pressure low (Amato)
Mechanical power can be roughly calculated at the bedside as a product of driving pressure and respiratory rate- this may become our key targeted variable in future (Amato)ncbi.nlm.nih.gov/m/pubmed/27620…
However both driving pressure and mechanical power remain static measures of lung mechanics. In future we’ll need dynamic bedside tools.
Ventilator dissynchrony remains a problem and contributes to mortality…. ncbi.nlm.nih.gov/pubmed/25693449
And of course there’s ECMO. Some patients still require ventilation while on ECMO and the reasons for this will vary- for some it will be gas exchange, for others it will be muscular (Camporotta).
There remain several unanswered questions in the ECMO population- how to wean, who needs (and doesn’t need) mechanical ventilation… hopefully answers will come.
The future may well be closed-loop ventilation, such as that seen with the Hamilton ventilators in their ASV mode.