Which ventilation strategy minimizes ventilator-induced lung injury in ARDS?

• A. Lung-protective ventilation with low tidal volumes and appropriate PEEP
• B. High tidal volumes to maximize CO2 clearance
• C. No PEEP to minimize barotrauma
• D. Permissive hypercapnia without PEEP

Answer: (A)

Minimizing ventilator-induced lung injury in ARDS comes from lung-protective ventilation: using small tidal volumes and adequate PEEP to prevent both overdistension and repetitive opening and closing of alveoli. Low tidal volumes (about 6 ml/kg predicted body weight) limit volutrauma by reducing the stretch on fragile lungs, and keeping plateau pressures under 30 cm H2O reduces barotrauma. Adequate PEEP helps keep alveoli open at end expiration, lowering atelectrauma and improving oxygenation, while still being titrated to avoid overdistension. This approach, supported by trials showing better outcomes with low tidal volumes and appropriate PEEP, addresses the main drivers of VILI.

High tidal volumes increase volutrauma and worsen lung injury. No PEEP allows alveolar collapse and repeated opening/closing (atelectrauma), worsening injury and oxygenation. Permissive hypercapnia without PEEP neglects the need to keep alveoli recruited; while permissive hypercapnia can be part of a lung-protective strategy, it is not compatible with a strategy that omits PEEP, and would not minimize injury in ARDS.