In Reply Using esophageal manometry to estimate pleural pressure helps delineate contribution of lung vs chest wall mechanics to clinically observed airway pressures. Transpulmonary pressure provides a truer estimate of distension of aerated lung parenchyma (ie, stress of the ventilated lung regions) than airway pressures alone. In preclinical ARDS models, injury ascribed to atelectrauma can occur from high shear forces generated during repetitive tidal reopening of fluid-filled or collapsed small airways.1 Drs Sklar and Goligher argue that chest wall mechanics are of negligible relevance to lung recruitability and individualizing lung-protective PEEP. Yet negative PL values (in which pleural pressure exceeds airway pressure) predispose to airway closure and maintaining airway pressure above pleural pressure reverses such closure,2 lending mechanistic plausibility to protective effects of setting PEEP accordingly in patients at risk of biophysical lung injury.
Beitler JR, Talmor D. Strategies to Adjust Positive End-Expiratory Pressure in Patients With ARDS—Reply. JAMA. 2019;322(6):580–582. doi:10.1001/jama.2019.7888
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