In a recent issue of the American Journal of Critical Care, Chian and colleagues presented a case report describing the management of a patient who developed acute respiratory distress syndrome (ARDS) following inhalation of gas from a smoke bomb.1 

Much of the report focused on the use of extracorporeal life support to overcome recalcitrant hypoxemia. I would like to comment briefly on the mechanical ventilation strategies that were employed.

The authors described numerous ventilator modes used in the effort to find optimal oxygenation response and patient-ventilator synchrony. Initial ventilator settings were a volume-controlled mode with a tidal volume of 500 mL. On day 16, the ventilator was changed to pressure-controlled ventilation that was programmed to produce a plateau pressure of 35 cm H2O. What is remarkable is that the authors contend that “protective ventilator strategies were used.” I would argue that they were not.

The ARDS...

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