Driving pressure during assisted mechanical ventilation: Is it controlled by patient brain?

•Provided that breathing pattern is not restricted critically ill patients control the driving pressure.•This control is achieved by sizing the tidal volume to individual respiratory system compliance.•When passive ventilation results in high driving pressure the spontaneously breathing patients decrease it.•The patients are adept to protect the lung by preventing high driving pressure.

Tidal volume (VT) is the controlled variable during passive mechanical ventilation (CMV) in order to avoid ventilator-induced-lung-injury. However, recent data indicate that the driving pressure [ΔP; VT to respiratory system compliance (Crs) ratio] is the parameter that best stratifies the risk of death. In order to study which variable (VT or ΔP) is controlled by critically ill patients, 108 previously studied patients were assigned to receive PAV+ (a mode that estimates Crs and permits the patients to select their own breathing pattern) after CMV, were re-analyzed. When patients were switched from CMV to PAV+ they controlled ΔP without constraining VT to narrow limits. VT was increased when the resumption of spontaneous breathing was associated with an increase in Crs. When ΔP was high during CMV, the patients (n = 12) decreased it in 58 out of 67 measurements. We conclude that critically ill patients control the driving pressure by sizing the tidal volume to individual respiratory system compliance using appropriate feedback mechanisms aimed at limiting the degree of lung stress.