Setting positive end-expiratory pressure: does the 'best compliance' concept really work?

Area of Science:

• Critical Care Medicine
• Respiratory Physiology

Background:

• Positive end-expiratory pressure (PEEP) optimization in acute respiratory distress syndrome (ARDS) is critical but controversial.
• The 'best compliance' strategy, aiming for peak respiratory system compliance, has conflicting evidence and potential safety concerns.

Approach:

• Critically evaluate the physiological rationale and limitations of the 'best compliance' strategy.
• Review emerging alternative methods for assessing lung mechanics and recruitment.
• Highlight the importance of personalized PEEP settings in ARDS management.

Key Points:

• The 'best compliance' strategy may not accurately reflect functional residual capacity or recruitment, and has been linked to increased mortality in ARDS.
• Compliance measurements can underestimate overdistension and neglect important factors like intra-tidal recruitment and patient-specific mechanics.
• Alternative techniques like recruitment-to-inflation ratio, nitrogen wash-in/wash-out, and electrical impedance tomography (EIT) offer more precise assessment of lung recruitment and overdistension.

Conclusions:

• The traditional 'best compliance' approach to PEEP setting in ARDS has significant limitations and potential risks.
• Novel techniques and technologies are emerging to provide more reliable and personalized strategies for PEEP optimization in ARDS.
• Future research should focus on validating these advanced methods for improved clinical application and patient outcomes.