Key messages

• The rapid development of cystic barotrauma usually presages the occurrence of tension pneumothorax. Effective secretion clearance, treatment of infection, and, most importantly, reduction of airway pressure are fundamental to management.

• In patients with acute respiratory distress syndrome ventilated with high tidal pressures and maintained with low left ventricular filling pressures, alveolar pressures may exceed those in the pulmonary veins. If alveolar rupture opens a communication pathway to the vascular system, this pressure gradient may drive air into the systemic circulation.

• Despite the importance of peak tidal alveolar pressure, there are many contributing predisposing variables: necrotizing and heterogeneous lung pathology, youth, copious retained airway secretions, and extended duration of positive-pressure ventilation.

• As a general rule, high peak pressures applied to a stiff lung cause less alveolar stretch than the same pressures applied to a compliant lung. Pneumothorax becomes much more likely at peak ventilator cycling pressures above 40 cmH2O.

• Failure to maintain a certain minimum end-expiratory transalveolar pressure (i.e. total PEEP) in the early phase of acute respiratory distress syndrome may intensify pre-existing alveolar damage, particularly when high tidal volumes and inflation pressures are used.

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