In moderate to severe ARDS, conversely, raising PEEP up to 15 cmH2O reopens a relevant proportion of lung tissue, possibly contributing to the clinical benefit by higher PEEP protocols documented in this subset of patients. It is widely accepted that PEEP setting should aim to a balance between its capability to recruit the collapsed tissue and the unavoidable damage generated in the “baby lung”. Results from the present elegant physiological study confirm that the amount of recruitable lung (and thus the mechanistic benefit from higher PEEP) depends on the severity of the disease.Īccordingly, in mild ARDS, the benefit of PEEP up to 15 cmH2O may be trivial and this approach is likely unnecessary, also considering robust clinical data showing no effect (or harm?) in milder patients treated with more aggressive PEEP-setting protocols. plateau pressure) seem to improve lung homogeneity in moderate and severe ARDS patients. Conversely, pressures far higher than set PEEP (i.e. Raising PEEP from 5 to 15 cmH2O enhances lung homogeneity in mild and moderate ARDS patients but not in the severe ones. The risk of intra-tidal recruitment increases with ARDS severity, and is not mitigated by setting PEEP at 15 cmH2O, as compared to PEEP = 5 cmH2O.Īs about gas distribution, the extent of inhomogeneities increases, but not significantly, along all the ARDS severity spectrum. Importantly, the recruited lung tissue between 5 and 15 cmH2O is minimal in mild, higher in moderate and maximal in severe ARDS both with and without ECMO. RESULTSĪs already reported by the same group, the total recruitability between 5 and 45 cmH2O increases with ARDS severity, being neglectable in mild, modest in moderate and greater in severe ARDS, independently from the use of ECMO.

CT scans were used to assess alveolar recruitment, atelectrauma (intra-tidal cyclic recruitment of collapsed areas) and ventilation inhomogeneities, which were the addressed endpoints. In addition, to quantify patients’ total recruitability (increase in the amount of aerated tissue as airway pressure is raised), CT scans were also conducted with airway pressure = 45 cmH2O.

The authors studied 33 ARDS patients with heterogenous disease severity (5 mild, 10 moderate, 9 severe and 9 severe receiving ECMO and ultra-low), who underwent CT scans at end-expiration and end-inspiration while receiving mechanical ventilation with low-tidal volumes and PEEP set both at 5 and 15 cmH2O.

recently reported the results of a physiological study to clarify whether the PEEP levels usually applied with the high-PEEP strategies really avoid atelectrauma and ensure adequate recruitment in ARDS patients.

In the 2000s, a ventilation strategy providing low-tidal volumes to avoid baro/volutrauma and higher PEEP to limit atelectrauma, has been suggested to mitigate VILI and protect the lung. Nonetheless, while low tidal volumes convincingly improve clinical outcome and are widely used in the daily practice, the benefit of higher PEEP remains controversial despite some positive results, with its use not so widespread in the clinical setting. Conversely, atelectrauma represents the cyclic opening and closing of alveoli during tidal ventilation and mainly happens at the edge between normally aerated and collapsed lung zones. During ARDS, Ventilator-Induced Lung Injury (VILI) occurs as a means of baro/volutrauma and atelectrauma and is a key factor in determining patients’ outcome. Barotrauma and volutrauma develop as a consequence of the excessive pressure/volume load to the aerated lung, which is markedly reduced by the disease (i.e.

Volutrauma vs barotrauma