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We appreciate Mr Haynes’ comments on the ventilation strategies targeted for ARDS specifically induced by inhaling grenade smoke. To protect from lung inflammation, improve lung mechanics and gas exchange, and prevent progression of multiple organ failure, a treatment guided by reports from the ARDS Network proposes a standard of care for ARDS.^1,2  This young man, 171 cm height and 61 kg weight, had developed subcutaneous emphysema, pneumomediastinum, and bilateral pneumothorax on the third hospital day.³ 

After bilateral tube thoracostomies, bilateral bronchopleural fistulas were diagnosed, with continuous bubbling in the water seal of the chest drainage device (see Figure), and mechanical ventilation was then applied. We have tried several ventilator modes to achieve the best oxygenation when 100% oxygen is needed.

Continuous mandatory ventilation functions best with bedside observation. The initial ventilator setting was continuous mandatory ventilation and the tidal volume was 500 mL for a...