Transpulmonary pressure targets for open lung and protective ventilation: One size does not fit all

摘要

More than 20 years ago Dreyfuss et al. and Hernandez et al. [1, 2] showed that ventilator-induced lung injury is better linked to transpulmo-nary pressure (P_L) than to airway pressure (P_(AW)). With this concept in mind Grasso et al. recently reported that using a P_L target, as opposed to a P_(AW) target, allowed them to use unconventionally high PEEP and end-inspiratory plateau pressure of the respiratory system (PPLAT_(RS)) in a subgroup of patients with ARDS associated with influenza A (H1N1) who were candidates for extracorpo-real membrane oxygenation (ECMO) due to life-threatening refractory hypoxemia [3]. In patients with high chest wall elastance (E_(CW)), the application of higher PEEP and PPLAT_(RS) allowed by this approach provided sufficient lung recruitment to avert the need for ECMO. This proof-of-concept report compellingly shows the limitations of P_(AW) to gauge ventilatory settings in the context of high E_(CW).