Mechanical ventilation with PEEP titrated above the lower inflection pressure of a static pressure-volume (V/P) curve and low Vt has been suggested to prevent tidal alveolar collapse at end-expiration and overdistension of lung units at end-inspiration during ARDS . This lung-protective ventilatory strategy has been found to improve lung compliance, venous admixture, and PaO2 without causing cardiovascular impairment in ARDS . Recently, a lung protective mechanical ventilation using Vt of not more than 6 ml/kg ideal body weight has been shown in large-scale clinical trials to improve outcome in patients with ARDS [58,59]. Based on these results the CPAP levels during APRV/BiPAP should be titrated to prevent end-expiratory alveolar collapse and tidal alveolar overdistension [58, 59]. In our investigations, CPAP levels were always adjusted. When CPAP levels during APRV/BiPAP were adjusted according to a lung-protective ventilatory strategy occurrence of spontaneous breathing improved cardiorespiratory function without affecting total oxygen consumption due to the work of breathing in patients with ARDS . These data clearly demonstrate that spontaneous breathing can improve gas exchange without any further increase in airway pressures during lung protective mechanical ventilation. Moreover, pulmonary compliance in this range of airway pressures is greatest meaning that spontaneous breathing is efficient even with minimal ventilatory effort .
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