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* Correspondence: jose.van.der. hoorn@ventinova.nl Ventinova Medical B.V., Meerenakkerplein 7, 5652, BJ, Eindhoven, The Netherlands To the editor The recent publication by Berlin et al. evaluated the effect of negative end-expiratory pressure (NEEP) on hemodynamic parameters during ventilation in a porcine model before and after hemorrhage, while NEEP was established using a prototype device with automated expiratory ventilation assistance (EVA) [1]. Compared to conventional volume controlled ventilation with positive end-expiratory pressure (VCV-PEEP) at similar minute ventilation, EVA-NEEP markedly improved hemodynamic parameters in hemorrhagic shock, without the need for massive infusion of fluids. At the same time, the authors noted a lower ventilation efficiency of EVA-NEEP compared to VCV-PEEP, as carbon dioxide (CO2) removal was reduced under the conditions chosen, while oxygenation was maintained. We feel it is worth pointing out that the application of EVA ventilation referred to in this study specifically corresponds to the use of EVA in combination with NEEP, which may be indicated in the special situation of hypovolemia to improve venous return and cardiac output, but does not reflect the main intended use of this technology. The EVA ventilation was initially developed as an emergency technique [2] and has been elaborated into FCV® as an alternative to conventional positive pressure ventilation. EVA/FCV® make use of the Venturi effect to control both inspiration and expiration. Based on continuously measured intratracheal pressures, EVA/FCV® ventilation provides a constant gas flow into or out of the lungs until the peak inspiratory or end-expiratory pressure aimed for is reached. Ventilation efficacy of EVA-PEEP was evaluated in healthy pigs by Schmidt et al. [3]. Their study demonstrated that during 6 h of ventilation, FCV-PEEP resulted in improved lung recruitment and arterial oxygenation (+ 10%, P = 0.002) as compared to VCV-PEEP at similar peak and PEEP pressures, while using a lower minute volume (− 21%, P = 0.04) [3]. Thus, the EVA/FCV® technology allows, but is not restricted to, negative pressure ventilation and can even represent a higher efficient alternative to conventional ventilation when using PEEP. Recently, FCV® has become available for clinical use (ventilator Evone®, Ventinova Medical, Eindhoven, the Netherlands) and has been shown to effectively ventilate patients using PEEP [4]. The manufacturer therefore recommends to apply NEEP ventilation only in situations of hemorrhagic shock.

Negative pressure ventilation: a special application of expiratory ventilation assistance