After a decade of evolving concepts about mechanical ventilation in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), it is now indisputablethatreducinglungstretchbylimitingtheend-inspiratorylungvolume powerfully impacts on the outcome of such patients [1, 2]. However, uncertainty remains concerning the relative role of the maintenance of the end-expiratory volume in the context of ALI/ARDS. The avoidance of lung collapse and cyclic reopening may probably determine further benefit on patient outcome but it is a much more complex hypothesis to be tested in randomized clinical trials than the simple reduction of lung stretch [3].

In this chapter, we review the evidence that air space collapse is a major feature of ALI/ARDS and that the presence of lung collapse, either persistent or cyclic, is detrimental. We also comment on the difficulties involved in the testing of a comprehensive protective strategy in the clinical arena.

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