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High PEEP may have reduced injurious transpulmonary pressure swings in the ROSE trial
Critical Care volume 23, Article number: 404 (2019)
Vigorous spontaneous inspiratory efforts can lower pleural pressures and increase transpulmonary pressures, worsening existing lung injury. Muscle paralysis  may prevent breath stacking and pendelluft associated with high respiratory drive and very negative pleural pressures. A recent and comprehensive study  compared two positive end-expiratory pressure (PEEP) strategies and found that an oxygenation-based method to select PEEP resulted in strong inspiratory efforts, high local lung stress, and intensely focused inflammation in dependent lung regions. In contrast, high PEEP rendered spontaneous effort less injurious by lowering the level of spontaneous effort via neuromechanical uncoupling (Fig. 1) and by converting solid-like (more atelectatic) lung to fluid-like (less atelectatic) lung, reducing the vertical gradient of inspiratory local negative swings in pleural pressure. Both mechanisms worked together to promote a more homogeneous lung expansion. One of the limitations of a high PEEP strategy is that mechanical ventilation with PEEP may result in longitudinal atrophy of diaphragm fibers . We postulate that in the ROSE trial [4, 5] the use of lung-protective ventilation with high PEEP (instead of a ventilation strategy with low PEEP ) reduced potentially injurious transpulmonary pressure swings in both groups, making the muscle paralysis unnecessary and preventing the potential harmful effects of strong spontaneous efforts in moderate-to-severe ARDS.
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The datasets used and/or analyzed reported here are available from the corresponding author on reasonable request.
Slutsky AS. Neuromuscular blocking agents in ARDS. N Engl J Med. 2010;363(12):1176–80.
Morais CCA, Koyama Y, Yoshida T, Plens GM, Gomes S, Lima CAS, Ramos OPS, Pereira SM, Kawaguchi N, Yamamoto H, et al. High positive end-expiratory pressure renders spontaneous effort noninjurious. Am J Respir Crit Care Med. 2018;197(10):1285–96.
Lindqvist J, van den Berg M, van der Pijl R, Hooijman PE, Beishuizen A, Elshof J, de Waard M, Girbes A, Spoelstra-de Man A, Shi ZH, et al. Positive end-expiratory pressure ventilation induces longitudinal atrophy in diaphragm fibers. Am J Respir Crit Care Med. 2018;198(4):472–85.
The National Heart, Lung, and Blood Institute PETAL Clinical Trials Network, Moss M, Huang DT, Brower RG, Ferguson ND, Ginde AA, Gong MN, et al. Early neuromuscular blockade in the acute respiratory distress syndrome. N Engl J Med. 2019;380(21):1997–2008.
Slutsky AS, Villar J. Early paralytic agents for ARDS? Yes, no, and sometimes. N Engl J Med. 2019;380(21):2061–3.
Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, Jaber S, Arnal JM, Perez D, Seghboyan JM, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363(12):1107–16.
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Borges, J.B., Morais, C.C.A. & Costa, E.L.V. High PEEP may have reduced injurious transpulmonary pressure swings in the ROSE trial. Crit Care 23, 404 (2019) doi:10.1186/s13054-019-2689-x