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To the Editor: Limiting plateau pressures in the respiratory system of patients with acute lung injury and acute respiratory distress syndrome (ALI/ARDS) to 28 to 30 cm H₂O may help guarantee lung protection.¹ In the large multicenter Express trial, Dr Mercat and colleagues² set positive end-expiratory pressure (PEEP) as high as possible to avoid plateau pressure above 28 to 30 cm H₂O (mean, 27.5 cm H₂O). In the lower PEEP (minimal distention) group in the Express trial, plateau pressure was kept as low as possible to maintain oxygenation targets (mean, 21 cm H₂O). There was no difference in mortality between the 2 groups, but the higher PEEP/plateau pressure (increased recruitment) group showed a greater number of ventilator-free and organ failure–free days. Plateau pressure in the increased recruitment group dropped to 24 cm H₂O within the first week.

Two smaller trials (n = 53³ and n = 103⁴) showed . . . [Full Text of this Article]

Jack J. Haitsma, MD, PhD
jack.haitsma@utoronto.ca
Interdepartmental Division of Critical Care Medicine
St Michael's Hospital
Toronto, Ontario, Canada

Paolo Pelosi, MD
Department of Ambient Health and Safety
University of Insubria
Varese, Italy

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