Normal Plateau Pressure on Mechanical Ventilation
Normal plateau pressure on mechanical ventilation should be kept at or below 30 cmH2O to prevent ventilator-induced lung injury. This is a strong recommendation supported by multiple clinical guidelines for patients requiring mechanical ventilation.
Plateau Pressure Targets
- Plateau pressure should be kept ≤30 cmH2O in patients with acute respiratory distress syndrome (ARDS) and other forms of respiratory failure 1
- For patients with normal lungs, plateau pressure should be kept ≤28 cmH2O, and in cases of increased chest wall elastance, ≤29-32 cmH2O 1
- In obstructive airway disease, plateau pressure should be maintained ≤30 cmH2O 1
- Recent evidence suggests that even lower plateau pressures (≤25 cmH2O) may be associated with better outcomes in septic patients with acute respiratory failure 2
Clinical Significance of Plateau Pressure
- Elevated plateau pressures are associated with ventilator-induced lung injury through alveolar overdistension 1
- Maintaining plateau pressure below 30 cmH2O is part of lung-protective ventilation strategies that have been shown to reduce mortality in ARDS patients 1
- There appears to be no absolute "safe" plateau pressure, with evidence suggesting that lower values may be beneficial when achievable 2
- Plateau pressure monitoring is recommended as a standard parameter for all mechanically ventilated patients 1
Special Patient Populations
- For patients with cirrhosis and acute-on-chronic liver failure requiring mechanical ventilation, a lung protective strategy with low plateau pressure (<30 cmH2O) is recommended 1
- In patients with healthy lungs undergoing surgery, plateau pressures of 16 cmH2O or less are associated with the lowest risk of postoperative respiratory complications 3
- For patients with obstructive airway disease, plateau pressure targets remain ≤30 cmH2O, but special attention should be paid to preventing air trapping 1
Relationship to Other Ventilator Parameters
- Plateau pressure should be considered alongside tidal volume (recommended at 6 mL/kg predicted body weight for patients with ARDS) 1
- When using positive end-expiratory pressure (PEEP), the plateau pressure limit still applies to the total pressure (PEEP + driving pressure) 1
- Driving pressure (plateau pressure minus PEEP) has been identified as an important predictor of outcomes in ARDS and may be a better target than plateau pressure alone 1
- Plateau pressure monitoring should be performed in conjunction with flow-time scalar observation to ensure accurate measurement 1
Measurement Techniques
- Plateau pressure should be measured during an inspiratory hold maneuver of 0.5-1.0 seconds 1
- For children <10 kg, pressure should be measured near the Y-piece of the patient circuit for accuracy 1
- Transpulmonary pressure (airway pressure minus pleural pressure) may provide additional information in patients with altered chest wall compliance 1
Practical Considerations
- If plateau pressure exceeds target levels, consider reducing tidal volume, increasing inspiratory time, or evaluating for patient-ventilator asynchrony 1
- In patients with increased chest wall stiffness, plateau pressures may exceed 30 cmH2O even when lung stretch is not excessive 1
- Experimental evidence from animal studies shows that even plateau pressures of 30 cmH2O can cause lung injury over time in previously healthy lungs 4
By maintaining plateau pressure within these recommended limits, clinicians can help minimize the risk of ventilator-induced lung injury while providing effective mechanical ventilation support.