CHEST Guidelines-Response_chest_4

Response_chest_4 - 1

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The document is a response from Dr. Domenico Luca Grieco and colleagues to Dr. Jha's comments on their study about the effects of positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome (ARDS) who are undergoing assisted mechanical ventilation. Dr. Jha emphasized the importance of lung strain and its role as an indicator of potential lung injury. However, Dr. Grieco argues that PEEP effects should not be solely judged based on lung strain, especially in cases of spontaneous breathing, where lung injury risks are not just tied to overall lung stress but also regional lung behavior differences.<br /><br />They highlight that regional heterogeneities are pivotal in lung injury, which Dr. Jha's commentary might not have sufficiently covered. Their study data showed that inspiratory effort and driving pressure increased to maintain target tidal volume when PEEP reduced compliance. This means tidal volume did not rise with increased inspiratory effort as hypothesized by Dr. Jha.<br /><br />The authors also respond to Dr. Jha's points on respiratory and hemodynamic responses to PEEP, emphasizing the challenges of assessing these without advanced monitoring. They provide a detailed table showing patient data divided by response to PEEP in terms of compliance and tidal volume, supporting their interpretation of the data.<br /><br />The response is followed by an unrelated commentary by Auguste Dargent and colleagues, discussing a different study about the use of dexmedetomidine in septic shock patients. They propose further studies using alpha-2 agonists without conventional sedatives and at higher doses for extended periods to better evaluate benefits.<br /><br />Overall, both responses address complex clinical challenges in respiratory and critical care medicine, advocating for nuanced approaches and further research.

Keywords

PEEP

ARDS

lung strain

mechanical ventilation

spontaneous breathing

regional heterogeneities

inspiratory effort

driving pressure

respiratory responses

dexmedetomidine