Education  |   June 2020
Driving Pressure for Ventilation of Patients with Acute Respiratory Distress Syndrome
Author Notes
  • From the Department of Anesthesiology and Department of Medicine, University of California, San Diego, La Jolla, California.
  • Submitted for publication July 23, 2019. Accepted for publication January 21, 2020. Published online first on February 20, 2020.
    Submitted for publication July 23, 2019. Accepted for publication January 21, 2020. Published online first on February 20, 2020.×
  • Address correspondence to Dr. Malhotra: University of California San Diego, 9500 Gilman Drive, La Jolla, California. amalhotra@ucsd.edu. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Education / Clinical Focus Review
Education   |   June 2020
Driving Pressure for Ventilation of Patients with Acute Respiratory Distress Syndrome
Anesthesiology 6 2020, Vol.132, 1569-1576. doi:https://doi.org/10.1097/ALN.0000000000003195
Anesthesiology 6 2020, Vol.132, 1569-1576. doi:https://doi.org/10.1097/ALN.0000000000003195
Invasive mechanical ventilation is a remarkable advance, but the possibility of ventilator-induced lung injury exists, particularly if the ventilator settings are not optimized. The best methods to avoid lung injury during mechanical ventilation, either during ventilation of healthy lungs in the operating room or during ventilation as support during critical illness, are topics of debate. In this review, we summarize the current evidence and review a relatively new concept to prevent lung injury: targeting driving pressure defined by plateau pressure minus positive end-expiratory pressure (PEEP; see table 1) when setting and adjusting mechanical ventilation.
Lung injury results from excess transpulmonary pressure (stress on the lung), lung stretch, and atelectrauma (lung injury from repetitive alveolar collapse).1  Transpulmonary pressure is measured as the airway opening pressure (i.e., that measured on the ventilator) minus the pleural pressure (estimated with esophageal manometry).2  One cause of high transpulmonary pressures (inside pressure minus outside pressure) is the delivery of large tidal volumes (VT).3  This situation can lead to high lung stress, causing lung injury and inflammation, and is associated with poor outcomes, particularly in acute respiratory distress syndrome (ARDS). In addition to lung stress from tidal inflation, atelectrauma is the damage caused by repetitive collapse of the lung at end-exhalation, and low PEEP settings may contribute to this pathophysiology.4