Is mandatory protective ventilation for all patients?

VT/IBW, set at 6 mL/kg IBW, is not the ideal setting for all patients. First, because in a subgroup of patients characterized by very low baby lung, it could be excessively high. In these patients alternative forms of respiratory assistance must be considered, as the extra-corporeal support. Second, because in another subgroup of patients characterized by a greater baby lung, 6 mL/kg VT/IBW could be unnecessarily low, increasing the risk of supplementary sedation, curarization and atelectasis. Therefore, in our opinion, the rational way to set the ventilation is to measure the lung volume and/or the transpulmonary pressure, as IBW and plateau airway pressure are inadequate surrogates. However, if in a given intensive care unit, there is not the possibility of such measurements a lower VT/IBW would be anyway a better choice than an higher one, as the risks associated with an unnecessary low tidal volume are lower than the ones associated with unnecessary high tidal volume.