To the Editor:—

We read the article “Controlled Airway Pressure Therapy, Nitric Oxide Inhalation, Prone Position, and Extracorporeal Membrane Oxygenation (ECMO) as Components of an Integrated Approach to ARDS”1with great interest, and we congratulate the authors for their well-conducted study. A lung-protective strategy with reduction of shear stress by keeping positive end-expiratory pressure above the lower inflection point and avoiding overdistension by keeping peak airway pressure below the upper inflection point of the pressure–volume curve produces good results.

At our institution, the ventilatory management of acute respiratory distress syndrome is pressure-controlled ventilation and the attempt to achieve optimal positive end-expiratory pressure derived from pressure–volume curves, as documented by Lazarus 2,3approximately 15 yr ago.

Although this first evidence of lung volume–oriented ventilation did not receive a good response, Ullrich et al.  1supported this approach in their large-scale clinical study. Therefore, clinical experience with the pressure–volume approach of the 1980s and recent scientific evidence should have the desired impact on ventilation strategy in critical care units.

We hope to gain more clinical experience from such studies to help us in critical care medicine in the 21st century. 4 

1.
Ullrich R, Lorber C, Röder G, Urak G, Faryniak B, Sladen RN, Germann P: Controlled airway pressure therapy, nitric oxide inhalation, prone position, and extracorporeal membrane oxygenation (ECMO) as components of an integrated approach to ARDS. A nesthesiology 1999; 91: 1577–86
2.
Lazarus G: End-inspiratory lung volume as the limiting factor of ventilation with PEEP (German). Anaesthesist 1983; 32: 582–90
3.
Lazarus G: PEEP ventilation without hyperinflation of the lung (German). Anaesthesist 1985; 34: 59–64
4.
Bigatello L, Hurford W, Pesenti A: Ventilatory management of severe acute respiratory failure for Y2K. A nesthesiology 1999; 91: 1567–70