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In Reply: Dr Oba proposes an approach to setting PEEP during ALI/ARDS based on the following conceptual model: by applying higher levels of PEEP the lung will be recruited and, with the tidal volume distributed across a greater portion of lung parenchyma, the plateau pressure will decrease; ie, the compliance of the respiratory system will increase. After the recruitment, a further increase of PEEP would lead to alveolar overdistention, and the compliance of the respiratory system would decrease accordingly. Indeed, the "best PEEP" would coincide with the "best compliance."

Investigators have been approaching this issue for more than 35 years^1-2 without having reached a solution. In 1975, Suter et al³ formulated the same proposal (best PEEP = maximum oxygen transport = maximum compliance). Unfortunately, things are not so simple for a number of reasons. First, lung recruitment is a continuous inspiratory phenomenon occurring up to total lung capacity⁴; it is impossible to dissociate . . . [Full Text of this Article]

Luciano Gattinoni, MD, FRCP
gattinon@policlinico.mi.it

Pietro Caironi, MD
Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore
Fondazione IRCCS–Ospedale Maggiore Policlinico Mangiagalli Regina Elena di Milano
Milan, Italy

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