Evolutionary patterns and research frontiers in ventilator-induced lung injury: a bibliometric analysis (2000–2024)

Introduction

Ventilator-induced lung injury (VILI) represents a common and serious complication of mechanical ventilation. Its development is influenced by multiple factors, including excessive tidal volume, elevated airway pressure, and alveolar overdistension (1-5). Improper mechanical ventilation may cause alveolar overdistension, triggering cellular inflammation and leading to pulmonary edema (6-9), which in turn reduces lung compliance and impairs gas exchange, thereby compromising oxygen delivery (10). Concurrently, VILI can initiate systemic inflammatory response syndrome and release inflammatory mediators such as tumor necrosis factor α (TNFα), interleukin (IL)-1β, and IL-6, thereby impairing the function of other organs, including the heart and kidneys (11). Mechanical ventilation-induced overstretch activates multiple intracellular inflammatory pathways, including NF-κB, MAPK, and NLRP3 inflammasome signaling, thereby promoting the release of pro-inflammatory mediators and amplifying lung injury (10-16). Despite these risks, positive pressure ventilation remains a vital supportive intervention for patients with respiratory failure in intensive care settings. In response to these challenges, researchers have investigated various strategies to prevent and manage VILI. Optimizing respiratory parameters such as tidal volume, inspiratory pressure, and respiratory rate is essential to minimizing excessive alveolar distension (17,18). Lung-protective ventilation strategies, particularly low tidal volume ventilation combined with appropriate positive end-expiratory pressure (PEEP), are considered central approaches for reducing VILI and improving outcomes in acute respiratory distress syndrome (ARDS) patients (19). Despite these advances, a comprehensive and systematic analysis of research in this field remains lacking. As research has advanced, increasing attention has been directed toward identifying inappropriate ventilation strategies that lead to VILI. Nevertheless, there is still a need for an exhaustive, multidimensional analysis incorporating elements such as publication volume, authorship, journals, countries/regions, and key research topics. Therefore, appropriate research methodologies are essential to address this gap.

Bibliometric analysis, rooted in mathematical and statistical principles, has become an established method for quantitatively evaluating research trends and collaborative networks across academic fields (20-22).

In the context of VILI research, bibliometric analysis offers a systematic approach to evaluating the current state of the field. By tracing the progression of VILI-related studies, this method reveals the evolution of research over time, identifies key contributors and institutions, and highlights emerging research foci. These insights are essential for future studies, providing a clearer strategy to address existing gaps and advance knowledge in the domain.

Established bibliometric indicators, including the h-index (23), g-index (24), and m-index (25), are employed to assess research impact and productivity.

With advances in computer science and information technology, bibliometrics—also referred to as scientometrics or literature analysis—has become increasingly reliant on sophisticated software for performing complex analyses and visualizations. Among the most widely used tools in this domain are Bibliometrix (26), VOSviewer (27), and CiteSpace (28), which play a crucial role in supporting academic research. Bibliometrix is an R software package designed specifically for the quantitative analysis of bibliometric and scientometric data. It provides a comprehensive set of tools that support various stages of scientometric analysis, from data collection to analysis and visualization. Key functions include data loading, bibliometric analysis, network construction, and data normalization. In addition, Bibliometrix offers advanced features for examining keyword co-occurrence and tracking the evolution of topics over time, making it an essential tool for researchers investigating trends and patterns in scholarly literature (26).

Although bibliometric techniques are widely used across various research fields, a comprehensive bibliometric study of VILI remains lacking. To date, no in-depth bibliometric or machine learning-based visualization study has been conducted on VILI. This study aims to address this gap by employing bibliometric methods to perform a systematic analysis of the relevant VILI literature. The analysis covers key aspects such as publication output, author distribution, research institutions, journal sources, and keyword frequencies. By mapping the research landscape of VILI, this study seeks to establish a scientific foundation and guide more targeted investigations in the field. We present this article in accordance with the BIBLIO reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0580/rc).

Methods

Bibliometric analysis was conducted using Bibliometrix (version 3.1), an R package for quantitative analysis of scientometric data (29), via the Biblioshiny web interface.

The data collection process began with extracting relevant literature from databases, including the Web of Science. Bibliometrix was then used for comprehensive data analysis, encompassing citation analysis and the examination of authors, journals, countries, institutions, and research themes.

For this study, Web of Science was chosen due to its comprehensive and well-curated coverage of academic literature, particularly in the medical field. Although Web of Science excludes certain grey literature, it is regarded as providing access to high-quality, peer-reviewed scholarly articles. This aligns with the study’s objective to conduct a thorough and reliable analysis of the VILI field.

The Web of Science Core Collection (WoSCC) database was selected as the primary data source because of its comprehensive coverage of high-quality medical literature, standardized citation indexing system, and widespread use in bibliometric studies (21,29). The literature search was conducted on June 15, 2024, covering publications from 2000 to 2024. The search strategy aimed to capture all literature concerning VILI and its relationship with mechanical ventilation. The following search was conducted on the Topic (TS) field, covering titles, abstracts, and keywords: TS=(“ventilator-induced lung injury” OR “VILI” OR (“mechanical ventilation” AND “lung injury”) OR “ventilator-associated lung injury” OR (“mechanical ventilation” AND “acute lung injury”)). Inclusion criteria: (I) directly related to VILI; (II) article or review; (III) English language. Exclusion criteria: (I) irrelevant to VILI; (II) meeting abstracts, editorials, or retracted publications; (III) duplicates.

Bibliometric analyses and visualizations were performed using Bibliometrix, VOSviewer, and CiteSpace, which are widely used tools for scientometric and knowledge-mapping studies (26-28).

The generated Excel file, processed through R bibliometric tools, includes key statistical data such as the total number of articles, author counts, and the h-index, g-index, and m-index for authors. It also contains data relevant to Lotka’s law, such as the distribution of article counts by author, as well as information on the most prolific journals. Furthermore, the file includes metrics such as the single-country publication (SCP) and multiple-country publication (MCP) ratios for countries, offering a comprehensive view of the bibliometric landscape.

Statistical analysis

Descriptive bibliometric indicators were used to summarize publication characteristics, including annual publication counts, citations, countries, institutions, journals, and authors. Quantitative analyses and visualization were performed using Bibliometrix in R software and VOSviewer. Continuous variables were summarized as frequencies, percentages, or bibliometric indicators where appropriate. No inferential statistical testing was required because all analyses were based on bibliographic records retrieved from the WoSCC.

Results

Overview of publication status

Table 1 indicates that the inaugural publication focusing on VILI was published in 2000. By June 15, 2024, this subject had yielded 557 articles, with an average yearly growth rate of 5.23%. This study includes 2,600 contributors, of which 7 are singleauthor studies. The average citation count per article is 27.29, amounting to a total of 13,964 citations. The average number of coauthors per article is 7.31. International partnerships account for 23.16% of these studies, reflecting collaborations among authors from different countries on collaborative projects. Table 1 provides a detailed summary of the key statistics.

Figure 1 illustrates the annual and cumulative number of publications (NP) related to VILI from 2000 to 2024. Since the first article was published in 2000, scholarly attention to VILI has steadily increased. By 2024, the total NP reached 557, reflecting a clear upward trend over the past two decades. Although there were some fluctuations in yearly output, the overall trend may suggest continuous growth, particularly after 2015. The most productive year was 2022, with 52 articles published. Between 2000 and 2023, the publication count showed consistent annual increases, highlighting the growing research interest in the VILI field. This publication trajectory not only reflects the maturation of VILI as a research topic but also indicates increasing international and interdisciplinary attention. The cumulative curve underscores the accelerating accumulation of knowledge in this domain.

Figure 1 Number of publications per year.

Best authors and journals

This research utilized a tripartite plot visualization to investigate the connections between crucial components in VILI studies (29). This method of analysis concurrently uncovers the structural links between key bibliometric areas—journals, authors, keywords, and countries—facilitating a comprehensive understanding of their interplay in the academic landscape. In the three-field plots, similar to Sankey diagrams, each field is depicted using colored rectangles. Each rectangle’s height reflects the aggregate intensity of the connections between its represented element and elements in neighboring fields. For example, a larger rectangle signifies stronger or more numerous associations. The design of this visual framework facilitates an immediate and intuitive grasp of the connections between journals, authors, countries, and keywords.

Figure 2 presents two tripartite plots: the first focusing on keywords-authors-journals, and the second on keywords-countries-journals. The left section highlights the journals with the highest NP on VILI-related research. These include prominent publishing platforms crucial for disseminating discoveries in the field. The middle section highlights the most productive authors and countries. This may suggest global participation in VILI research, underscoring the diverse contributions of researchers from different countries to this domain. Notably, countries such as China, the United States, and Germany exhibit considerable engagement. Within this context, China may suggest a specific emphasis on studies related to inflammation. The right section presents the most frequently used keywords, reflecting the primary research topics. These include terms such as “ventilator-induced lung injury”, “mechanical ventilation”, and “acute respiratory distress syndrome (ARDS)”, highlighting key scientific research areas.

Figure 2 Three-field plots for ‘keywords-authors-journals’ and ‘keywords-country/region-journals’. SO, source; AU, author; CO, country; DE, descriptors.

Utilizing such three-field mapping enables (I) the identification of major publishing venues in the VILI domain; (II) the highlighting of prominent researchers and active countries; and (III) the identification of primary research subjects attracting academic focus. The study identifies ten key authors instrumental in the development of this field: Bates JHT, Rocco PRM, Smith BJ, Garcia JGN, Nieman GF, Schultz MJ, Slutsky AS, Sammani S, Wang YL, and Zhang HB. Moreover, three principal journals have emerged as key publication platforms: Frontiers in Physiology, American Journal of Physiology Lung Cellular and Molecular Physiology, and American Journal of Respiratory and Critical Care Medicine. These journals have been pivotal in disseminating significant discoveries, thereby underscoring their role in VILI research.

A total of 2,600 authors contributed to VILI research. According to Figure 3, Garcia JGN emerged as the most prolific author, with a total of 24 articles and an h-index of 18. Bates JHT, Smith BJ, and Wang YL followed closely, each having contributed 17 articles. Authors including Nieman GF, Sammani S, Rocco PRM, Schultz MJ, Slutsky AS, Gatto LA, Pan LH, Gu CP, Wang T, and Zhang HB have authored over 10 papers each.

Figure 3 Publication numbers of authors.

Table 2 displays the h-index, g-index, m-index, total citations (TC), NP, and year of first publication (PY_start) for the top 20 contributors to VILI research. Garcia JGN is recognized as the leading author in VILI research, with a publication record of 24 articles since 2005. His h-index is 18, indicating that each of his 18 most cited papers has received at least 18 citations. With a g-index of 24, his highly cited papers have accumulated a total of 1,004 citations, reflecting their significant influence. With an m-index of 0.9, Garcia may suggest a moderate productivity level relative to his career length.

Based on the bibliometric indicators in Table 2, Garcia JGN, Slutsky AS and Sammani S constitute the core academic group in VILI research with outstanding TC and long-term stable productivity. A clear tiered distribution exists among contributors: senior investigators who began publishing in the early 2000s maintain sustained academic influence, while newly emerging scholars from China represented by Wang YL and Pan LH show fast-growing research output in recent years. The differentiation of m-index further reveals divergent developmental trajectories: veteran researchers enjoy accumulated citation advantages, whereas younger authors display higher annual productivity efficiency.

Bates JHT, Smith BJ, and Wang YL each authored 17 papers, with an h-index of 10, reflecting their consistent contributions over time, albeit with fewer citations than the top contributors, with 408, 205, and 229 citations, respectively.

Several authors have published over 10 articles, including Schultz MJ (13 publications, h-index 10), Jacobson JR (9 publications, h-index 9), Pan LH (12 publications, h-index 9), and Zhang HB (10 publications, h-index 9). Nieman GF, Gu CP, Wang T, and Hoetzel A also belong to this group, each making notable contributions to VILI research in terms of publication volume.

Authors such as Wang YL (first publication in 2013), Pan LH, and Dai HJ, though relatively new to the field, have already made significant impacts, as evidenced by their m-index scores (0.7 to 0.9) and citation counts, indicating their rapid rise in the research community. Authors such as Gatto LA, Haitsma JJ, and Nieman GF have extensive careers in this domain, with their earliest works dating back to the early 2000s. The values of their h-index and g-index demonstrate steady contributions and notably high citation frequencies, particularly considering their career lengths.

An elevated h-index indicates that an author has published a considerable number of papers with high citation rates. For example, Garcia JGN’s h-index of 18 may suggest his consistent publication of significant research in the field. Conversely, authors with an h-index ranging from 7 to 9, such as Albaiceta GM and Birukov KG, have fewer highly cited works, yet their consistent contributions remain significant.

The g-index considers the citation counts of an author’s most frequently cited articles. Authors with a higher g-index, such as Slutsky AS (g-index =13) and Garcia JGN (g-index =24), tend to have higher TC, indicating a more substantial influence in their field of study.

The m-index, calculated by dividing the h-index by the number of years since the author’s first publication, aids in assessing an author’s research output in relation to career length. For example, Garcia JGN’s m-index of 0.9 indicates a consistent and moderate productivity level relative to his career length. Authors such as Bates JHT and Smith BJ, with m-indices in the range of 0.625 to 0.75, demonstrate consistent but less intensive research output.

The TC column offers a distinct perspective on the overall influence of their research. Garcia JGN tops the list with 1,004 citations, while authors such as Slutsky AS and Sammani S also exhibit high citation counts, reflecting the recognition their contributions have garnered in the VILI field.

Figure 4 depicts the collaborative network of researchers engaged in VILI research. Within the network, the size of each circle corresponds to the NP by a given author, while the color of the circle indicates the author’s cluster group. A total of 95 authors, each with five or more publications, were classified into 18 distinct groups based on their research collaborations. Among these groups, the teams led by the three most productive authors—Garcia JGN, Bates JHT, and Rocco PRM—are shown to collaborate closely. These authors form a central hub within the network, indicating a high degree of interaction and joint research efforts.

Figure 4 Collaboration network of authors.

In contrast, the research teams led by Wang YL and Pan LH in China appear to be relatively isolated, with no significant collaboration with other countries in the VILI field. This highlights a gap in international cooperation, suggesting that stronger research ties between Chinese researchers and their international counterparts could benefit the field.

Additionally, the network includes nine smaller clusters that exist outside of the more prominent research communities. These smaller groups show no collaboration with the larger, more established teams, indicating that these researchers operate independently or with limited connections to other major research groups. This lack of integration suggests that the cooperation between VILI research teams in China and other countries may need to be strengthened.

Lotka’s law describes the frequency distribution of scientific productivity, indicating that most authors publish only a small number of papers while a limited number of authors contribute extensively. This law was used to evaluate author productivity patterns in VILI research. Figure 5 illustrates the frequency of author productivity in VILI research, as predicted by Lotka’s law. The horizontal axis represents the number of articles, while the vertical axis shows the proportion of authors across different productivity levels. In the figure, the dashed line represents Lotka’s law, which predicts that approximately 60% of authors will have one article, 15% will have two, and 7% will have three. In the context of VILI research, this distribution aligns well with Lotka’s predictions. Specifically, 73.3% of authors have one publication, 15.5% have two, 5% have three, 2.6% have four, and 0.9% have five (see Table 3). This trend indicates that most authors have published one article, aligning with Lotka’s general principle. However, authors who have published more than five papers are considered key contributors in this field. It is likely that these authors have a deeper understanding of VILI and have consistently and significantly enriched the body of literature.

Figure 5 Lotka’s law.

The top 20 journals account for approximately half of the scientific contributions in the field, with the top five journals comprising a substantial portion of this output (Table 4). American Journal of Physiology Lung Cellular and Molecular Physiology leads in citation count (1,604) and publication volume, followed by Critical Care, Frontiers in Physiology, PLoS One, and American Journal of Respiratory and Critical Care Medicine. American Journal of Physiology Lung Cellular and Molecular Physiology has the highest h-index, g-index, m-index, and TC.

Figure 6 displays the annual publications from the top five journals in VILI, highlighting those that have made significant contributions to this field and related subjects. In 2000, American Journal of Respiratory and Critical Care Medicine published the first articles in this field, with two articles. Nevertheless, the journal’s annual publication volume remained modest, with a gradual increase in the number of articles. In contrast, American Journal of Physiology Lung Cellular and Molecular Physiology published its first article in 2004 and has emerged as the leading journal in terms of VILI article publications. The journal has shown a distinct increase in its publication volume. Since its inception in VILI research in 2016, Frontiers in Physiology has experienced a significant increase in articles published since 2019, with a particularly marked increase in recent years. Collectively, these trends illustrate the evolving publication landscape in VILI research, with established journals maintaining steady contributions while newer openaccess venues demonstrate rapid growth.

Figure 6 Source growth.

Bradford’s law

Bradford’s law describes the distribution of core journals within a research field, suggesting that a relatively small number of journals account for the majority of publications. This principle was applied to identify the most influential journals in VILI research. Using the Biblioshiny program (see Figure 7), nine key journals were identified as foundational and influential in the field. These journals are recognized for their pivotal role in advancing VILI research. The key journals identified are: American Journal of Physiology Lung Cellular and Molecular Physiology, Critical Care, Frontiers in Physiology, PLoS One, American Journal of Respiratory and Critical Care Medicine, International Immunopharmacology, Intensive Care Medicine, Respiratory Research, and American Journal of Respiratory Cell and Molecular Biology. These journals are considered crucial in shaping the research landscape of VILI, reflecting their significant academic influence and relevance.

Figure 7 Bradford’s law.

Productivity and collaboration networks of countries and institutions

An analysis of national publication data was conducted to identify the countries that have significantly contributed to the field. Figure 8A illustrates the global distribution of VILI-related publications, in which nations marked in dark blue represent those with the highest publication outputs. Among these countries, China and the United States were the most productive contributors to VILI research. Furthermore, collaboration network analysis demonstrated that the United States occupied a central position in international scientific cooperation, with Germany serving as its strongest collaborative partner, followed by China (Figure 8B).

Figure 8 Countries’ collaboration world map.

A total of 492 papers were published by the top ten countries in terms of publication volume, accounting for 88.33% of all publications in this field. China ranked first with 188 publications, followed by the United States with 151 publications. In addition, the United States participated in nine international collaborative relationships among the top ten countries, highlighting its pivotal role in promoting global cooperation in VILI research.

The global citation distribution is presented in Figure 9, where countries shown in darker blue achieved higher citation counts, reflecting their greater academic influence and scientific impact in the field of VILI research.

Figure 9 Each country’s contribution to VILI. VILI, ventilator-induced lung injury.

Nations with an MCP rate of 50% or higher demonstrate substantial global collaboration in the field of VILI. Austria, New Zealand, Brazil, and France are the nations that have exceeded this benchmark. Figure 10 and Table 5 display the SCP and MCP rates for these nations. Notably, the MCP rate for China is 4.79%, indicating a predominantly local publication pattern compared to other major contributors.

Figure 10 Corresponding author’s countries. MCP, multiple country publications; SCP, single country publications.

The volume of work published by various institutions reflects their impact on VILI research. Approximately 568 institutions worldwide have conducted studies on VILI. Figure 11 illustrates that among the top 20 institutions, 12 are based in the United States, which correlates with the nation’s leading publication volume. Despite China’s top position in total publication volume, only three of its institutions are ranked in the top 20. Germany, which holds the third position in terms of publication volume, has three institutions ranked in the top 20. In Canada, where only two institutions rank in the top 20, the University of Toronto is the leading institution, with 100 published papers.

Figure 11 The top 20 institutions with the most publications in the field of VILI. VILI, ventilator-induced lung injury.

Understanding the contribution patterns of countries and institutions in VILI research, a further analysis of keywords in this field helps to comprehensively grasp the current research landscape. The most frequently occurring words in the literature are highlighted using the word cloud method (Figure 12). It shows the frequency of word occurrence in the sample data. The higher the frequency with which a word appears, the larger its size in the selected sample. This analysis can evaluate current research trends, identify gaps in the field of VILI, and suggest potential research areas. Bibliometrix software analyzes the words using the abstracts and references of the articles.

Figure 12 Word cloud.

The top-ranked keywords in the abstracts are positioned in the center of the map according to their frequency of occurrence in the articles, including lung, VILI, injury, ventilation, mechanical, mice, and ventilator-induced. Additionally, keywords including expression, inflammatory, tidal, levels, volume, increased, IL, protein, respiratory, alveolar, and pulmonary appear in the papers. This figure indicates that the literature primarily focuses on the core concepts of lung injury, pulmonary edema, and the inflammatory response caused by VILI, which increases the levels of inflammatory mediators such as IL-6 and IL-18.

The analysis obtained from the bibliographies of the articles is called Keywords Plus. Keywords Plus is extensively used in bibliometric studies of topic mapping (30). Keywords with the highest frequency, including mechanical ventilation, activation, inflammation, expression, and end-expiratory pressure, are mostly located in the center of the map. Among the words with lower occurrence frequency, including model, inhibition, injury, cytokines, cells, and tidal volume, their size is smaller than that of the top-ranked words, but they remain more prominent than the vast majority of words.

In recent years, keyword co-occurrence network (KCN) analysis has been used for knowledge mapping. In a KCN, each keyword is depicted as a node, and each cooccurrence of a pair of words is represented as an edge. The frequency with which a pair of words co-occurs in multiple articles constitutes the weight of the edge connecting that pair of words. Thus, the constructed network represents the cumulative knowledge of a given field and facilitates the discovery of meaningful knowledge components and insights based on edge patterns and strengths between keywords appearing in the literature (31). Co-occurrence networks are employed to identify the dynamics of the conceptual structure in a given field, to identify topics related to specific research paths, and to track the evolution of concepts (32).

As shown in Figure 13, the keywords in VILI publications form two main clusters. The first cluster, shown in red, contains 23 keywords, with the most prominent being respiratory distress syndrome, mechanical ventilation, and end-expiratory pressure. The second cluster, shown in blue, contains the most prominent keywords, including activation, inflammation, and expression. Researchers have emphasized that VILI triggers inflammatory response activation and the subsequent release of inflammatory mediators.

Figure 13 Co-occurrence network by Keywords Plus.

Co-occurrence network analysis was further used to identify the topics within a given field, the relationships between these topics, their internal structure, and their concentration. Consequently, by applying clustering algorithms to the keyword network, different topics can be presented and displayed on the map. To illustrate the growth of the topic and its relevance to the broader scientific field, the horizontal axis represents centrality and the vertical axis represents density. The thematic map (Figure 14) further illustrated the conceptual structure and developmental maturity of VILI-related research topics. Based on this, four research quadrants are identified in the field of VILI. Quadrant 2 (upper left corner) represents a niche theme, comprising activation, inflammation, expression, inhibition, cytokines, cells, mice, oxidative stress, apoptosis, and epithelial cells. Quadrant 4 (lower right corner) represents a basic theme, comprising respiratory distress syndrome, mechanical ventilation, endexpiratory pressure, model, injury, tidal volume, pressure, recruitment, acute lung injury, and mortality.

Figure 14 Thematic map.

Figure 15 illustrates the evolution of research on VILI over time. Since 2001, VILI has been linked to dominant topics such as respiratory distress syndrome, with researchers initially focusing on the physiological changes induced by VILI. By 2008, the scope of research expanded to include topics such as permissive hypercapnia, TNFα, and RNA expression, suggesting that the occurrence of VILI could lead to changes in these factors. From 2009 to 2010, research centered on high airway pressure, septic shock, nitric oxide synthase, nitric oxide, and endotoxin, reflecting a shift toward investigating the causes of VILI. Between 2011 and 2016, the focus expanded significantly to include topics such as pulmonary edema, in vivo studies, endothelial cells, cytokines, tidal volume, VILI, epithelial cells, respiratory failure, airway pressure, expression, end-expiratory pressure, mortality, inflammatory responses, mechanical stretch, mechanical ventilation, animal modeling, and recruitment maneuvers. During this period, researchers increasingly conducted animal experiments to study the mechanisms associated with VILI, applied modeling techniques (e.g., mechanical ventilation and mechanical stretch), and observed the progression of pulmonary edema and cellular damage. From 2017 to 2018, the research focus shifted to topics such as activation, airway pressure, acute lung injury, inflammation, inhibition, and lung injury. Researchers began to recognize VILI as a form of acute lung injury, the occurrence of which triggers the release of inflammatory mediators. Analyses after 2019 reveal a growing focus on topics such as cellular mechanisms, signaling pathways, patient survival, NLRP3 inflammasome, lung mechanics, receptors, mechanical strain, clinical outcomes, driving pressure, and ARDS. During this period, researchers began examining the effects of various cell types on VILI. The formation of the NLRP3 inflammasome emerged as a key mechanism in the cascade triggered by VILI, prompting investigations into strategies to reduce lung injury by inhibiting this pathway.

Figure 15 Trend topics.

Discussion

This study conducted a comprehensive bibliometric analysis of research on VILI, systematically revealing publication trends, research hotspots, influential authors, core journals, and collaborative networks in this field. The findings provide a comprehensive understanding of the current research landscape and future directions for VILI studies.

Research growth and evolutionary trajectory

The continuous increase in VILI-related publications since 2000 reflects increasing global attention toward VILI in critical care. A clear inflection point around 2008 marks the beginning of a phase of accelerated scientific output, driven by growing recognition of iatrogenic lung damage in ICU settings (33-37).

This upward trend parallels broader developments in critical care medicine, including the digitalization of clinical data, refinement of ventilatory strategies, and increased adoption of evidence-based ICU protocols (38). Notably, keyword evolution and thematic analyses revealed a growing focus on inflammatory signaling pathways, inflammasome activation, and molecular mechanisms after 2015, which may suggest increasing interest in mechanism-oriented and data-driven research approaches in VILI (12-16).

Scientific landscape and global collaboration patterns

The bibliometric data illustrate a geographical imbalance in knowledge production. The United States leads both in research output and in international collaboration, serving as a global hub in VILI research networks. Conversely, while China ranks highest in publication volume, its MCP rate of 4.79% suggests a need for increased global engagement.

Smaller yet collaborative countries such as Austria and New Zealand demonstrate high MCP ratios, emphasizing the value of collaborative intensity over sheer volume. Strengthening cross-continental research consortia, particularly those that integrate Asian and Western institutions, may promote knowledge equity, methodological innovation, and more diverse clinical data representation.

Core publication ecosystem and knowledge dissemination

Consistent with Bradford’s law, a small group of journals accounts for a large portion of VILI publications. Among them, American Journal of Physiology Lung Cellular and Molecular Physiology remains the leading platform for high-impact mechanistic studies. The rise of open-access journals, especially Frontiers in Physiology, has facilitated broader visibility and accessibility, enabling researchers from developing regions to contribute more substantially.

This trend may suggest improved accessibility and broader dissemination of VILI-related research findings.

Conceptual shifts in VILI research focus

Thematic evolution in keywords indicates a clear paradigm shift:2000–2008: emphasis on ventilatory parameters (e.g., tidal volume, plateau pressure); 2009–2016: expansion toward cytokine biology, apoptosis, and oxidative stress;2017–present: focus on molecular immunopathogenesis, especially the NLRP3 inflammasome, NF-κB signaling, and other inflammatory cascades (12-16,39).

These trends reflect a transformation in the understanding of VILI from a biomechanical complication to a mechano-immunological process. The activation of mechanosensitive signaling pathways in alveolar macrophages and epithelial cells underscores the intimate link between physical stimuli and inflammatory gene expression, offering novel intervention targets. For instance, the NLRP3 inflammasome has surfaced as a molecular “bridge” that connects mechanical stretch with innate immune activation, offering new therapeutic targets to mitigate lung injury (13,39).

Mechanistic framework: a multiaxial injury model

Current knowledge frames VILI within a triaxial pathophysiological model: the mechanical axis is presented as follows. Repetitive overdistension and alveolar collapse generate shear forces and stretch injury. Inflammatory axis: mechanical stress activates intracellular pathways (NF-κB, MAPK), triggering release of IL-1β, TNF-α, and IL-6. Oxidative axis: reactive oxygen species (ROS) production exacerbates cellular injury and amplifies inflammation through a self-sustaining loop. Pharmacological studies indicate that disrupting these axes—particularly at crosstalk nodes such as NLRP3 and NF-κB—can attenuate VILI in preclinical models (13,15). However, translation to clinical practice remains limited, underscoring the need for multi-target, system-level interventions that address both mechanical and molecular drivers simultaneously.

Clinical translation and the rise of precision ventilation

The development of lung protective ventilation (LPV) strategies, notably those pioneered by Amato et al. (19), has significantly improved survival in patients with ARDS. Nonetheless, LPV remains a population-averaged approach, and interindividual variability in lung mechanics and inflammatory phenotypes calls for precision-driven ventilation strategies.

Recent advancements, such as electrical impedance tomography (EIT) and artificial intelligence (AI)-assisted ventilator control systems, may facilitate real-time and individualized adjustment of ventilatory settings (40,41). However, many of these technologies remain in the investigational or early clinical application stage, and their effects on patient-centered outcomes have not yet been confirmed in large-scale randomized controlled trials.

Pharmacologic adjuncts targeting mechanotransduction pathways could complement mechanical strategies, shifting treatment from reactive damage control to proactive injury prevention at the cellular level.

Bibliometric methodology: strengths and gaps

While bibliometric tools offer valuable insights into research structure and dynamics, their limitations warrant consideration:

• Database restriction: reliance on a single database (Web of Science) may exclude relevant regional, non-English, or open-access publications.
• Different databases, such as Web of Science, Scopus, and Google Scholar, offer distinct advantages and limitations for quantitative analysis. Scopus provides broader journal coverage but may employ different citation algorithms that can affect citation counts and metrics. Google Scholar, while offering an extensive dataset, lacks strict quality control, which can affect the accuracy and reliability of the data. Given these factors, careful consideration must be given when selecting a database for analysis.
• Citation bias: metrics such as the h-index tend to favor older publications and may not fully reflect true innovation.
• Coauthorship analysis reveals structural patterns but does not capture the depth or quality of collaborative relationships.

To address these limitations, future bibliometric studies should incorporate multidatabase triangulation (e.g., Scopus, PubMed) and semantic network modeling, enabling more accurate identification of emerging research trends and influential conceptual shifts.

Through a systematic bibliometric analysis encompassing publications, authorship, journals, institutional output, and keyword evolution, this study provides a comprehensive overview of the global research landscape on VILI. The findings demonstrate a sustained upward trend in publication volume, with China and the United States emerging as the most prolific contributors. Influential authors, leading journals, and high-output research institutions are identified, collectively forming the intellectual core of the field.

The analysis further reveals evolving research priorities, with growing emphasis on lung-protective ventilation strategies, mechanistic exploration of inflammatory responses, and the search for reliable biomarkers. These thematic concentrations suggest a paradigm shift from empirical management toward mechanism-based precision interventions.

Conclusions

This study not only maps the current state of VILI research but also proposes clear directions for future inquiry. Interdisciplinary integration—linking critical care, molecular biology, engineering, and data science—will be essential to close the translational gap. Key priorities include:

• Refinement of individualized ventilation strategies;
• Targeted regulation of inflammatory and oxidative stress pathways;
• Development of diagnostic and prognostic biomarkers;
• Establishment of global research collaborations to standardize protocols and share clinical data.

Ultimately, by aligning future research efforts with both clinical needs and mechanistic insights, the VILI research community can advance toward improved patient outcomes, minimizing ventilator-associated complications and enhancing the safety and efficacy of mechanical ventilation.

Acknowledgments

The authors thank Massimo Aria and Corrado Cuccurullo. They provide the bibliometrix-package for free access by researchers.

Footnote

Reporting Checklist: The authors have completed the BIBLIO reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0580/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0580/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0580/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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