Mechanical Ventilation Guidelines for Plateau Pressure

Introduction to Plateau Pressure Targets

• The American Thoracic Society recommends keeping plateau pressure ≤30 cmH2O in patients with acute respiratory distress syndrome (ARDS) and other forms of respiratory failure 1, 2
• For patients with normal lungs, the European Society of Intensive Care Medicine suggests keeping plateau pressure ≤28 cmH2O, and in cases of increased chest wall elastance, ≤29-32 cmH2O 3
• In obstructive airway disease, the American Thoracic Society recommends maintaining plateau pressure ≤30 cmH2O 3

Clinical Significance and Monitoring of Plateau Pressure

• Elevated plateau pressures are associated with ventilator-induced lung injury through alveolar overdistension, according to the American Thoracic Society 2
• The Society of Critical Care Medicine states that maintaining plateau pressure below 30 cmH2O is part of lung-protective ventilation strategies that have been shown to reduce mortality in ARDS patients 1, 4
• Plateau pressure monitoring is recommended as a standard parameter for all mechanically ventilated patients by the European Society of Intensive Care Medicine 3

Special Considerations for Patient Populations

• For patients with cirrhosis and acute-on-chronic liver failure requiring mechanical ventilation, the American Association for the Study of Liver Diseases recommends a lung protective strategy with low plateau pressure (<30 cmH2O) 5, 6
• In patients with obstructive airway disease, the European Society of Intensive Care Medicine suggests that plateau pressure targets remain ≤30 cmH2O, but special attention should be paid to preventing air trapping 3

Relationship to Other Ventilator Parameters and Measurement Techniques

• The American Thoracic Society recommends considering plateau pressure alongside tidal volume (recommended at 6 mL/kg predicted body weight for patients with ARDS) 2, 4
• When using positive end-expiratory pressure (PEEP), the Society of Critical Care Medicine states that the plateau pressure limit still applies to the total pressure (PEEP + driving pressure) 7
• The European Society of Intensive Care Medicine suggests measuring plateau pressure during an inspiratory hold maneuver of 0.5-1.0 seconds 3

Ventilator-Induced Lung Injury and Barotrauma Risk

Primary Clinical Implications

• Elevated plateau pressure significantly increases the risk of barotrauma (pneumothorax, pneumomediastinum) in mechanically ventilated patients 8
• In ARDS trials, neuromuscular blockade was administered when plateau pressure exceeded 32 cmH₂O to prevent further pressure-related complications 8