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00:00:00 intro 00:02:33 balancing harm and protection with sedation 00:06:43 VILI ,P SILI 00:08:53 dyssynchrony 00:09:33 biotrauma 00:10:46 sedation and respiratory drive 00:13:33 REVERSE TRIGGERING phenotypes 00:16:45 dyssyncrony index 00:19:00 benefits of sedatives 00:21:47 volatile sedatives 00:25:38 NMBA , ACURYSYS TRIAL 00:27:55 ROSE TRIAL 00:38:00 role of esophageal mannometry 00:40:17titration to Chest Wall 00:44:17future 00:45:00 discussion Dr. Kassis and team to develop new metrics for monitoring sedation that target lung protection rather than just sedation level.• Research team to conduct more studies on which breathing patterns and forms of dysynchrony are actually harmful versus benign.• Dr. Cassis and colleagues to publish results of the INSPIRE study on inhaled anesthetics in the ICU.• .Lung Protective Sedation in Critically Ill Elias discussed the challenges of balancing the benefits and harms of sedation and neuromuscular blockade in critically ill patients. He highlighted the potential risks of deep sedation, including diaphragm injury, prolonged intubation, and increased death rates. Elias also presented data showing an increased burden of sedation during the COVID-19 pandemic. He proposed a new approach called "lung protective sedation," which involves targeted sedation practices with personalized goals, improved monitoring, and a balance between patient effort and dissynchrony. Lung Protective Sedation for Ventilator Patients Elias discussed the concept of personalized goals for sedation, particularly for patients at risk of ventilator-induced lung injury. He highlighted the importance of lung protective sedation in avoiding atelectrauma, barotrauma, and volutrauma, which can lead to mechanical injury and biotrauma. Elias also introduced the concept of self-inflicted lung injury, which occurs when a patient's own breathing activities cause additional mechanical injury. He emphasized the need to limit this injury, particularly in the sickest patients, and suggested that lung protective sedation could involve reducing the injurious level of effort or allowing spontaneous breathing. Dysynchrony, or the lack of synchrony between the patient's efforts and the ventilator's actions, was also discussed as a potential harm that could be addressed through lung protective sedation. Sedatives and Dysynchrony in Respiratory Drive Elias discussed the effects of sedatives on respiratory drive and their relationship with respiratory depression. He highlighted the variability of these effects and the differences between sedation depth and patient effort into synchrony. Elias also presented findings on reverse triggering, a form of dysynchrony that may be unmasked by deeper levels of sedation, and its potential harm to patients. He suggested that the harm from dysynchrony may not be directly caused by the synchrony itself, but by the sedation used to treat it. Elias concluded by emphasizing the need for further investigation into the relationship between sedation and dysynchrony. Efficacy of Analgesics and Sedatives Elias discussed the effectiveness of analgesics and sedatives in patient synchrony, citing a 2019 study by Deharo et al. that found opioids were the most effective at suppressing asynchrony. He also mentioned the use of dexmetamidine, a sedative with less respiratory suppression, in difficult-to-wean patients. Elias also discussed the potential benefits of ketamine in mechanically ventilated patients, as it decreased the work of breathing with increasing doses. He also touched on the use of inhaled anesthetics, which may have anti-inflammatory effects beneficial in patients with sepsis and ventilator-induced lung injury. Inhaled Anesthetics in ICU: Benefits and Drawbacks Elias discussed the potential benefits and drawbacks of using inhaled anesthetics in the ICU. He presented data from various studies, including a retrospective study on 200 secure patients and a study comparing Sibofluorine and Midazolam. Elias discussed the complexities of reverse triggering in patients, particularly those with severe ARDS and hypoxemia. He noted that not all reverse triggering requires intervention, and the approach to addressing it is often empirical. Elias suggested that in some cases, reverse triggering may be more similar to inspiratory efforts in patients, and in such cases, intervention may not be necessary. However, in more severe cases, reverse triggering can lead to significant increases in tidal volume, and in these cases, intervention may be required. Elias also mentioned that the treatment approach may vary depending on the type of dysynchrony and the patient's overall condition.