The ‘open lung’ approach has been proposed as a
reasonable ventilation strategy to mitigate ventilatorinduced
lung injury (VILI) and possibly reduce
acute respiratory distress syndrome (ARDS)-related
mortality. However, several randomized clinical trials
have failed to show any signifi cant clinical benefi t
of a ventilation strategy applying higher positive
end-expiratory pressure (PEEP) and low tidal volume.
Dispute regarding the optimal levels of PEEP in ARDS
patients represents the substrate for a translational
research eff ort from the bedside to the bench, driving
animal studies aimed at elucidating which ventilation
strategies reduce biotrauma, considered one of the
most important driving forces of VILI and ARDS-related
multi-organ failure and mortality. Inappropriate values
for end-inspiratory or end-expiratory pressure have
clear potential to damage a lung predisposed to VILI.
In the heterogeneous environment of the ARDS ‘baby
lung’, lung recruitment and the avoidance of tidal
overstretch with high-frequency oscillation ventilation
or conventional mechanical ventilation, guided by
respiratory mechanics, appears to reduce VILI.