Strategies to Decrease Peak and Plateau Pressures

Understanding Airway Pressures

Peak airway pressure represents the maximum pressure measured during inspiration and is influenced by both airway resistance and lung/chest wall compliance 1
Plateau pressure reflects alveolar pressure at end-inspiration and is primarily determined by lung/chest wall compliance 1, 2
Maintaining plateau pressures <30 cmH2O is recommended to prevent ventilator-induced lung injury in ARDS patients 1, 3

Switching from volume-controlled to pressure-controlled ventilation can reduce peak airway pressures while maintaining the same tidal volume 4
Pressure-controlled ventilation provides a decelerating flow pattern that may distribute gas more evenly throughout the lungs 4
This mode change doesn't affect plateau pressures but can significantly reduce peak pressures 4

Improve patient-ventilator synchrony to reduce work of breathing and peak pressures 5
Address flow-asynchrony by adjusting flow patterns to match patient demand 5
Consider sedation adjustments if asynchrony persists and is contributing to elevated pressures 5

Address factors that decrease chest wall compliance, such as draining pleural effusions or ascites that may be restricting chest wall movement 6
Position the patient optimally to maximize chest expansion 2
Consider prone positioning in severe ARDS cases, which can improve lung mechanics and reduce plateau pressures 5
Adjust I:E ratio to allow for more complete exhalation, which can reduce air trapping and auto-PEEP 1
Increasing expiratory time by shortening inspiratory time can help reduce plateau pressures in patients with obstructive lung disease 1, 5

Regularly measure both peak and plateau pressures to assess the effectiveness of interventions 3
Calculate driving pressure (plateau pressure - PEEP) as it's a strong predictor of outcomes in ARDS patients 4
Driving pressures exceeding 15 cmH2O are of particular concern and should prompt reassessment of ventilation strategy 4

Changing to pressure-controlled ventilation may result in variable tidal volumes if lung compliance changes 4
When addressing chest wall compliance issues, ensure hemodynamic stability is maintained during interventions like drainage procedures 6
While these strategies can reduce pressures, they don't replace the need to consider tidal volume reduction if plateau pressures remain >30 cmH2O despite these interventions 1, 2

Plateau pressure requires zero flow conditions to accurately reflect end-inspiratory alveolar pressure, which can only be achieved by occluding the airway at end-inspiration, as recommended by the American Thoracic Society 7
The inspiratory hold maneuver allows pressure equilibration between the proximal airway and alveoli, eliminating the resistive component of airway pressure, according to the American College of Chest Physicians 7

For lung-protective ventilation targeting Pplat ≤30 cmH₂O, the inspiratory hold maneuver remains mandatory, as stated by the Society of Critical Care Medicine 7
Driving pressure (Pplat - PEEP) is a stronger predictor of outcomes than plateau pressure alone, with values >15 cmH₂O being particularly concerning, as reported by the American Thoracic Society 7