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Piling on the pressure to combat acute respiratory distress syndrome: a PEEP into the future?

There was a time, not too long ago, when the elaboration of acute respiratory distress syndrome (ARDS) was tantamount to an accelerated demise. Acute respiratory distress syndrome secondary to trauma, infection or, most commonly, sepsis – a damning feature of life in the intensive care unit – was historically associated with shockingly high mortality rates. J. S. Inkster’s clever introduction of residual positive pressure developed in the late 1960s in the practice of neonatal anaesthesia – an exemplar of the application of basic physiology to clinical treatment – soon found widespread use by intensivists in view of the improvements bestowed upon pulmonary function in critical care scenarios across the age spectrum. Positive end-expiratory pressure (PEEP) was born, and not a moment too soon! Nearly 50 years on from its introduction, PEEP is considered by its many proponents to be a remarkable success story. The premise of its application during low-volume mechanical ventilation is alveolar recruitment (‘open-lung’ ventilation), which protects distal airways from cyclic atelectasis, the repeated injurious inflation and collapse of functional gas-exchange units. Moreover, haemodynamic effects of PEEP can mitigate the severity of pulmonary oedema. Whilst the mortality rate in ARDS remains appreciable, it has plummeted in recent years, primarily, it is generally thought, due to preventative measures related to low-volume ventilation. Increasingly, however, it is suggested that PEEP has had no small part to play in that progress. One short sleep past, we wake eternally, And Death shall be no more; Death, thou shalt die. John Donne – Death be not proud