Recognizing and managing excessive respiratory drive and effort: an expert narrative review

Introduction: Patient self-inflicted lung injury (P-SILI) has been proposed as a contributor to lung damage during spontaneous breathing or partially assisted ventilation. P-SILI usually arises from excessive inspiratory efforts driven by abnormally elevated respiratory drive. Assessing respiratory drive and effort is therefore crucial for identifying patients at risk and guiding tailored lung-protective strategies. Areas covered: This narrative review provides practical recommendations for the identification and management of patients at risk of developing P-SILI. Expert opinion: Accurate assessment of respiratory drive and effort–using ventilator-derived parameters, esophageal manometry, diaphragm electromyography, and imaging modalities–is vital, though not yet standard in clinical practice. Management should aim to correct underlying causes of heightened drive, optimize sedation and ventilator settings, and apply advanced lung-protective interventions when appropriate. Future priorities include improving monitoring techniques, clarifying whether inspiratory effort or lung stress should be prioritized, and determining optimal timing for intubation. Balancing excessive and insufficient effort is essential, as both P-SILI and diaphragmatic disuse can worsen outcomes. Emerging imaging technologies may enhance real-time assessment of regional strain and effort. Ultimately, integrating physiological monitoring with individualized ventilatory management is fundamental to protect the lung while preserving respiratory muscle function and improving patient outcomes.