Are You Down With TPP? Considering Transpulmonary Pressures as Opposed to Ventilator-Measured Pressures

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Preventing intraoperative ventilator-induced lung injury is an important and evolving clinical goal in the practice of anesthesia. Lung protective ventilation (LPV) strategies have been studied for more than 2 decades, both in the critical care setting and, more recently, in the intraoperative period.1–6 Mechanical ventilation can lead to lung injury through several mechanisms including elevated tidal volumes (TVs; volutrauma), pressures (barotrauma), or shear stress from repeated cycles of opening and closing of atelectatic alveoli (atelectrauma).7 These processes can result in inflammation that may lead to increased risk of pulmonary complications. While minimizing both intraoperative volutrauma and barotrauma seems to be largely validated, the importance of appropriate positive end-expiratory pressure (PEEP) selection to prevent atelectrauma remains less clear.5 Unique scenarios encountered solely in the intraoperative period, such as steep Trendelenburg positioning and laparoscopic abdominal insufflation, make identification of mechanical ventilation parameters that minimize lung trauma especially challenging.
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