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REVIEW article

Front. Med.

Sec. Intensive Care Medicine and Anesthesiology

Volume 12 - 2025 | doi: 10.3389/fmed.2025.1692488

This article is part of the Research TopicAdvanced Monitoring in ARDS: Enhancing Mechanical Ventilation through Innovative TechniquesView all 7 articles

Real-Time Stress and Strain Monitoring at the Bedside: New Frontiers in Mechanical Ventilation

Provisionally accepted
Tommaso  PettenuzzoTommaso Pettenuzzo1Francesco  ZarantonelloFrancesco Zarantonello2Alessandro  ZambianchiAlessandro Zambianchi1Gianluca  LumettiGianluca Lumetti2Domenico  RuggeriniDomenico Ruggerini1Giorgia  PacchiariniGiorgia Pacchiarini2Elisa  PistollatoElisa Pistollato2Valentina  FincatiValentina Fincati1Giulia  MormandoGiulia Mormando1Alessandro  De CassaiAlessandro De Cassai1Nicolò  SellaNicolò Sella1*Annalisa  BoscoloAnnalisa Boscolo1Paolo  NavalesiPaolo Navalesi1
  • 1Universita degli Studi di Padova, Padua, Italy
  • 2Azienda Ospedale Universita Padova, Padua, Italy

The final, formatted version of the article will be published soon.

Mechanical ventilation is a fundamental intervention in intensive care medicine, providing vital support for patients with severe respiratory failure. However, this life-sustaining therapy also carries the risk of harm. Ventilator-induced lung injury (VILI) is now predominantly understood in terms of lung overdistension, characterized by excessive stress and strain on pulmonary tissue. In recent years, a variety of novel monitoring strategies have emerged, from refined measurements of respiratory mechanics to advanced imaging and physiologic modeling, to help in bedside detection of excessive lung stress and strain. Electrical impedance tomography is a non-invasive tool providing real-time imaging of regional ventilation and assisting in the diagnosis of overdistension and its minimization through positive end-expiratory pressure titration, also during partial support ventilation. Pleural and lung ultrasound might also suggest the occurrence of overdistension, although clinical data are still preliminary. Bedside maneuvers, such as changing patient positioning or applying abdominal weights, can help identify overdistension by observing change in respiratory mechanics. Ventilator-based methods like the recruitment-to-inflation ratio and the overdistension index help assess the risk of overdistension, despite requiring careful interpretation and validation. Biomarkers such as Clara cell secretory protein-16 and stretch-induced gene signatures represent a promising avenue for real-time monitoring of lung injury, though further validation is needed. These tools aim to help clinicians individualize ventilator settings, balancing adequate gas exchange with lung protection. Despite this progress, most techniques remain in the realm of research. Few have undergone the rigorous physiological and clinical validation necessary for routine bedside use. As the critical care community moves toward more personalized ventilation strategies, establishing reliable, real-time methods to assess lung stress and strain at the bedside will be key to translating innovation into improved patient outcomes.

Keywords: Ventilator-Induced Lung Injury, Overdistension, Lung stress, Lung strain, ElectricalImpedance Tomography, Lung ultrasound, Respiratory Mechanics, Pendelluft

Received: 25 Aug 2025; Accepted: 17 Sep 2025.

Copyright: © 2025 Pettenuzzo, Zarantonello, Zambianchi, Lumetti, Ruggerini, Pacchiarini, Pistollato, Fincati, Mormando, De Cassai, Sella, Boscolo and Navalesi. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Nicolò Sella, nicolo.sella@aopd.veneto.it

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