To the Editor: Limiting plateau pressures in the respiratory system of patients with acute lung injury and acute respiratory distress syndrome (ALI/ARDS) to 28 to 30 cm H2O may help guarantee lung protection.1 In the large multicenter Express trial, Dr Mercat and colleagues2 set positive end-expiratory pressure (PEEP) as high as possible to avoid plateau pressure above 28 to 30 cm H2O (mean, 27.5 cm H2O). In the lower PEEP (minimal distention) group in the Express trial, plateau pressure was kept as low as possible to maintain oxygenation targets (mean, 21 cm H2O). There was no difference in mortality between the 2 groups, but the higher PEEP/plateau pressure (increased recruitment) group showed a greater number of ventilator-free and organ failure–free days. Plateau pressure in the increased recruitment group dropped to 24 cm H2O within the first week.
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