How to optimize driving pressures and plateau pressures (Pplat) in mechanical ventilation?

From the Guidelines

To optimize driving pressures and plateau pressures (Pplat) in mechanical ventilation, aim to maintain driving pressure below 15 cmH2O and plateau pressure below 30 cmH2O. This approach is supported by recent studies, including those published in Critical Care and the American Journal of Respiratory and Critical Care Medicine 1. Implementing a lung-protective ventilation strategy with tidal volumes of 6-8 mL/kg of predicted body weight is crucial, as it reduces the risk of ventilator-induced lung injury and improves patient outcomes 1.

Some key points to consider when optimizing driving pressures and Pplat include:

• Measuring plateau pressure using an inspiratory hold maneuver (0.5-1 second) and calculating driving pressure by subtracting PEEP from plateau pressure
• Adjusting tidal volumes and respiratory rates to maintain minute ventilation while minimizing lung stress
• Optimizing patient-ventilator synchrony through adjustments in flow rates and sedation
• Positioning patients with head-of-bed elevation to 30-45 degrees and considering prone positioning for severe cases
• Ensuring appropriate PEEP settings to prevent atelectasis while avoiding overdistension

These strategies are supported by evidence from studies such as those published in the American Journal of Respiratory and Critical Care Medicine 1, which demonstrate the importance of lung-protective ventilation in reducing morbidity and mortality in mechanically ventilated patients. Additionally, a study published in Intensive Care Medicine highlights the importance of avoiding high driving pressures and promoting cardiac function through optimized respiratory settings 1.

By prioritizing these strategies and maintaining driving pressure below 15 cmH2O and plateau pressure below 30 cmH2O, clinicians can minimize ventilator-induced lung injury and improve outcomes for patients with acute respiratory distress syndrome.

From the Research

Optimizing Driving Pressures and Plateau Pressures (Pplat) in Mechanical Ventilation

To optimize driving pressures and plateau pressures (Pplat) in mechanical ventilation, several factors need to be considered:

• The patient's lung mechanics and the presence of acute respiratory distress syndrome (ARDS) play a crucial role in determining the optimal settings 2, 3.
• Driving pressure (∆P) is a key parameter that can help identify patients prone to develop ventilator-induced lung injury (VILI) and is associated with mortality 2, 3.
• The use of tidal volume (VT) limited to 6 ml/kg of predicted body weight is recommended, but adjustments may be necessary based on the patient's individual lung mechanics and plateau pressure 4, 5.

Adjusting Settings to Optimize Driving Pressures and Pplat

The following adjustments can be made to optimize driving pressures and Pplat:

• Titrate VT to minimize ∆P, especially when it is higher than 14 cmH2O, while considering the costs in terms of CO2 clearance 2.
• Use positive end-expiratory pressure (PEEP) to reduce ∆P, but be cautious of the potential for increased mortality with high PEEP levels 3.
• Consider the use of prone position and simple ventilatory adjustments to facilitate CO2 clearance and reduce ∆P 2.
• Monitor plateau pressure and adjust VT accordingly to prevent alveolar over-distension, with a commonly quoted threshold of 30-35 cmH2O 4, 6.

Considerations for Individualized Ventilation Strategies

Individualized ventilation strategies should take into account the patient's:

• Lung mechanics and disease severity 3, 5.
• Tolerance for CO2 clearance and acceptable levels of pH and P(aO2) 4.
• Risk of air trapping and intrinsic positive end-expiratory pressure (PEEP) with increasing respiratory frequency 4.
• Potential benefits and risks of high-frequency ventilation (HFV) as an "ultimate" lung-protective strategy 4.