High positive pressure at end expiration and recruitment maneuvers—is there a place for this therapy in acute respiratory distress syndrome?

The use of mechanical ventilation (MV) in patients with acute respiratory distress syndrome (ARDS) can exacerbate lung injury, which is usually referred to as ventilator-induced lung injury (VILI). The two most important mechanisms involved in VILI are the excessive volume or pressure that occurs at the end of inspiration, and the repetitive opening and closing of the alveoli. Therefore, lung protective ventilation strategy is based on the use of low tidal volumes and the prevention of intratidal collapse of pulmonary units by providing an appropriate level of positive pressure at end expiration (PEEP). In turn, some authors propose the use of recruitment maneuvers prior to the titration of the PEEP level (1,2) through the conception of open the lung and keep it open (3).