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American Journal of Respiratory and Critical Care Medicine Vol 173. pp. 686, (2006)
© 2006 American Thoracic Society

Correspondence

Is There a Safe Plateau Pressure Threshold for Patients with Acute Lung Injury and Acute Respiratory Distress Syndrome?

To the Editor:

Hager and colleagues in their recent article (1) presented the relationship of mortality as a function of Day 1 plateau pressure (Pplat), using data from the Acute Respiratory Distress Syndrome (ARDS) Network trial, and concluded that it does not reveal a safe Pplat threshold in patients with acute lung injury (ALI) and ALI/ARDS. An alternate interpretation of the mortality–plateau pressure curve presented in Figure 1 of Reference 1 is that it represents a composite of three relationships (shown here in Figure 1).


Figure 1
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  		Figure 1. Mortality versus Day 1 plateau pressure.

 
In region A, patients have relatively low respiratory system compliance, and mortality is reduced in direct proportion to the decrease in Pplat, with a slope of 0.015. Thus, reducing Pplat from point 1 to point 2 (55 to 45 cm H2O) would result in an absolute mortality reduction of about 15%. The curve in region B exhibits similar characteristics, except for higher respiratory system compliance despite ALI/ARDS. The slope is estimated to be 0.023. Last, the mortality curve in region C (Pplat 18 to 28 cm H2O) appears to be relatively insensitive to plateau pressure or tidal volume changes. The slope is estimated to be 0.002, which is eightfold lower than that of region A. In other words, attempts to further reduce Day 1 Pplat beyond approximately 30 cm might not significantly improve survival. Results from other studies for mean Pplat between 22.3 and 31.6 cm H2O also showed no mortality difference (2–4). The precise determination of this upper limit Pplat would require further analysis, and it may indeed represent a threshold for a "safer" pressure.

Kelvin K. Shiu and Mark J. Rosen

Beth Israel Medical Center, New York, New York

FOOTNOTES

Conflict of Interest Statement: Neither author has a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

REFERENCES

  1. Hager DN, Krishnan JA, Hayden DL, Brower RG. Tidal volume reduction in patients with acute lung injury when plateau pressures are not high. Am J Respir Crit Care Med 2005;172:1241–1245.[Abstract/Free Full Text]
  2. Stewart TE, Meade MO, Cook DJ, Granton JT, Hodder RV, Lapinsky SE, Mazer CD, McLean RF, Rogovein TS, Schouten BD, et al. Evaluation of a ventilation strategy to prevent barotrauma in patients at high risk for acute respiratory distress syndrome. Pressure- and Volume-limited Ventilation Strategy Group. N Engl J Med 1998;338:355–361.[Abstract/Free Full Text]
  3. Brower RG, Shanholtz CB, Fessler HE, Shade DM, White P Jr, Wiener CM, Teeter JG, Dodd-o JM, Almog Y, Piantadosi S. Prospective, randomized, controlled clinical trial comparing traditional versus reduced tidal volume ventilation in acute respiratory distress syndrome patients. Crit Care Med 1999;27:1492–1498.[CrossRef][Medline]
  4. Brochard L, Roudot-Thoraval F, Roupie E, Delclaux C, Chastre J, Fernandez-Mondejar E, Clementi E, Mancebo J, Factor P, Matamis D, et al. Tidal volume reduction for prevention of ventilator-induced lung injury in acute respiratory distress syndrome. The Multicenter Trail Group on Tidal Volume Reduction in ARDS. Am J Respir Crit Care Med 1998;158:1831–1838.[Abstract/Free Full Text]




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Copyright © 2006 American Thoracic Society