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We read with interest the study of Lakhal and colleagues [1] suggesting that respiratory pulse pressure variation (PPV) is not an accurate predictor of fl uid responsiveness in patients with acute respiratory distress syndrome (ARDS) ventilated with low tidal volume (Vt). Th ey stated that the poor performance of PPV is attributed to small changes in respiratory pleural pressure related to low Vt, such that PPV is low even in the case of marked cardiac preload dependency. Th ese fi ndings are not surprising since in this study [1] the mean static compliance was not very low (40 cmH 2 O); therefore, the percentage of transmission of alveolar pressure to the pleural space was not really altered. Th us, the ventilation with low Vt induced small variations in pleural and transpulmonary pressures. It must be stressed, however, that patients with ARDS usually exhibit a severe decrease in lung compliance and high plateau pressure. Moreover, in ARDS patients ventilated with low Vt, application of relatively high levels of positive end expiratory pressure (between 10 and 15 cmH 2 O) is now recommended [2]. Consequently, respira tory changes in transpulmonary pressure should remain greater than normal, and in spite of reduced lung compliance, cyclic changes in intrathoracic pressure may still be high enough for PPV to predict fl uid responsiveness [3]. Th e fi ndings of Lakhal and colleagues [1] perhaps provide insuffi cient support for the assertion that PPV is unable to predict volume responsiveness in ARDS patients ventilated with low Vt. Additional studies in severe ARDS patients (compliance <30 cmH 2 O) are necessary to investigate whether or not PPV could be used in such cases.

Ability of respiratory pulse pressure variation to predict fluid responsiveness in ARDS: still an unanswered question?