High-inflation pressure and positive end-expiratory pressure. Injurious to the lung? Yes.

There is a growing body of evidence suggesting that high levels of inflation pressure and high levels of PEEP may be injurious to lung tissue and other organ systems. Limiting peak alveolar pressures below 35 cm H2O may help in avoiding these injuries. The findings have led to the development of a lung-protective strategy that is based on physiologic parameters. This strategy, often using permissive hypercapnia and pressure-limited modes of ventilation, may gain widespread use in the near future. If this strategy reduces barotrauma, a reduction in the length of time on mechanical ventilation and mortality rates can be anticipated. At our center we routinely initiate mechanical ventilation in patients with acute lung injury, using tidal volumes of approximately 6 mL/kg. This may be decreased further if peak alveolar pressures exceed 30 to 35 cm H2O. PEEP is added to maximize alveolar recruitment and oxygenation. Optimal PEEP is located at the inflection point of the respiratory compliance curve. Usually a PEEP of 8 to 12 cm H2O is sufficient. Although we usually initiate mechanical ventilation with a volume-cycled mode, we are not hesitant to switch rapidly to a pressure-limited mode if results are unsatisfactory. We believe that more attention to the potential harmful effects of pressure and volume on lung architecture may result in further improvement of survival in patients with acute respiratory failure.