A model of mechanical power in mechanical ventilation and the concept of algorithm for managing VILI risk

Objective. A narrative review and conceptual synthesis of mechanical power (MP) of ventilation as an integral indicator of energy load, to discuss concepts of energy distribution and dissipation in respiratory system including elastic power and hazardous elastic power and to explore potential application of this parameter in clinical strategies for prevention of ventilator-induced lung injury (VILI). Material and methods. A narrative review with conceptual synthesis followed SANRA recommendations and incorporated elements of PRISMA 2020. Systematic searching was performed in PubMed/MEDLINE, Scopus, Web of Science, and Embase databases (1990–2025). The manuscripts devoted to mechanical power (MP), elastic power, hazardous elastic power, dissipated energy, threshold opening pressure, micro-strain and macro-strain, static and dynamic strain, MP normalization, as well as the influence of obesity, pneumoperitoneum and Trendelenburg position on respiratory mechanics were analyzed. Primary screening identified 87 unique sources; 37 publications were selected for detailed analysis. Synthesis was framed within mechanisms of VILI, and dual-sector MP management concept was formulated. Results. Two qualitatively distinct determinants of MP elevation were identified: increased metabolic demand for ventilation (minute ventilation) and deteriorated respiratory system mechanics (pressure, positive end-expiratory pressure, opening threshold pressure). Concepts of dissipated energy, elastic power, airway opening pressure, recruitment/de-recruitment energy dissipation and lung strain clarify where and how energy is distributed that determines the risk of VILI. Normalization of MP to respiratory system compliance or ideal body weight improves prognostic accuracy. A dual-sector clinical-physiological model for MP management was proposed. This model prioritizes correction of modifiable non-respiratory factors before optimization of ventilation parameter. Conclusion. Mechanical power and related characteristics of energy distribution and dissipation may be operational indicators of VILI risk. The proposed dual-sector model represents a conceptual framework for individualizing protective ventilation. Its clinical efficacy and impact on outcomes require prospective validation.