Entangled in stagnant recruitment delusions

Excerpt

We read with great interest the editorial by Gattinoni et al. regarding “Assessing lung recruitability: does it help with PEEP settings?” [1]. They explain that the necessary positive end-expiratory pressure (PEEP) to keep the recruited pulmonary units open is determined solely by their physical attributes, rather than by the potential for lung recruitment. Recruitment denotes the process by which previously collapsed and poorly ventilated pulmonary units transition to a better-inflated state during inspiration. This temporary transition occurs with a gradual increase in transpulmonary pressure, typically reaching thresholds of around 25–30 cmH₂O, which opens alveolar units with slow time constants [1]. Recruitment is integral to lung-protective ventilation strategies in patients with acute respiratory distress syndrome (ARDS), aiming to re-expand atelectatic lungs and improve lung compliance. However, it can lead to significant fluctuations in transpulmonary pressure and regional overinflation, potentially causing ventilator-induced lung injury (VILI) and multiorgan failure. Recent ARDS guidelines advise against the use of high-pressure (≥ 35 cmH₂O) recruitment maneuvers due to associated risks [2]. …