Which parameter is prioritized to minimize ventilator-induced lung injury in ARDS?

• A. Low FiO2.
• B. High PEEP regardless of plateau pressure.
• C. Tidal volume of 8-10 mL/kg.
• D. Plateau pressure ≤30 cm H2O with low tidal volumes (4-6 mL/kg PBW) and adequate PEEP.

Answer: (D)

Protecting the lung from ventilator-induced injury in ARDS means preventing both overdistension of the alveoli and excessive pressure while still achieving adequate oxygenation. The best approach is lung-protective ventilation: use small tidal volumes based on predicted body weight and keep the plateau pressure during inspiration at or below about 30 cm H2O. This combination minimizes volutrauma (from large tidal volumes) and barotrauma (from high pressures). Adequate PEEP is important to keep alveoli open and improve oxygenation, but it must be applied without driving plateau pressures above the safe limit. Thus, a strategy of low tidal volumes (4-6 mL/kg PBW) with careful monitoring to keep plateau pressure ≤30 cm H2O, plus adequate PEEP, best minimizes ventilator-induced lung injury. Lower FiO2 helps reduce oxygen toxicity, but it does not address the mechanical injury risk as directly as limiting tidal volume and plateau pressure. High PEEP without regard to plateau pressure can cause overdistension, making it less protective.