The “open lung” compromise

How best to select positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS) remains among the most actively debated questions critical care practice. Controversy stems partially fromimprecision of disease diagnosis, confusion about which objective to prioritize, and uncertainty regarding safe limits for airway pressure. Perhaps the root cause such indecisiveness, however, involves the mechanical heterogeneity of the acutely diseased lung coupled with the need to set only one PEEP value. In fact, when lung protection is the issue, PEEP selection is always a trade of between improving recruitment and increasing tissue stress. The article by Di Rocco and colleagues in the issue [1] offers novel experimental data that address how that compromise is best struck.