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Rebuttal From Dr MariniRebuttal From Dr Marini

John J. Marini, MD
Author and Funding Information

From the Pulmonary and Critical Care Section, Regions Hospital and the University of Minnesota.

Correspondence to: John J. Marini, MD, Regions Hospital, Pulmonary and Critical Care Medicine, MS 11203B, 640 Jackson St, St. Paul, MN 55101-2595; e-mail: john.j.marini@healthpartners.com


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;140(2):292-293. doi:10.1378/chest.11-1085
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Extract

Dr MacIntyre’s1 well-framed argument favoring volume assist-control ventilation centers on its ability to assure a specific and “safe” tidal volume (Vt), while downplaying the adverse effects of an unvarying Vt and a stereotyped flow profile on ventilator-induced lung injury, comfort, and synchrony. In the wake of the successful ARDS Network multicenter trial of tidal volumes (ARMA),2 a mystique has grown up around the need to always target 6 mL/kg predicted body weight. However, 6 mL/kg predicted body weight is neither safe nor appropriate for all. In fact, Vt size should vary breath to breath and should increase in parallel with minute ventilation, provided that doing so does not require excessive alveolar pressures. Note that normally, Vt increases more than fourfold during moderate exercise and that enforcing the 6 mL/kg rule on a 60-kg individual breathing 15 L/min would result in a machine frequency of 42/min. The perceived “error” that experienced clinicians commit when using Vt > 6 mL/kg is not necessarily a mistake if they avoid overpressurizing the lung, but rather it is a rational decision to enhance comfort and, thereby, avoid deeper sedation, which itself is not risk-free.3

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