PEEP zero. Is this the answer?

Inspiring discussion on Twitter (Minh Le Cong@rfdsdoc, Karim Brohi @karimbrohi and Peter Sherren@PBSherren)

The topic:

Your hypotensive blunt/penetrating trauma patient with associated severe TBI needs a vent. How do you set it and how you achive your physiological goals?

Is it possible to mantain eucapnia, avoiding hypercapnic insult to the brain, using low minute ventilation strategy and not depressing stroke volume with high intrathoracic pressure?

“Permissive hypoventilation” in a swine model of hemorrhagic shock.

Conclusions: Although permissive hypoventilation leads to respiratory acidosis, it results in less hemodynamic suppression and better perfusion of vital organs. In severely injured penetrating trauma patients, consideration should be given to immediate transportation without PPV.

But what if we have concomitant severe TBI? How can we avoid respiratory acidosis and hypercapnia (due to hypoventilation) and conseguent insult to the brain?

Is PEEP…