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EPVent-2 evaluated whether PEEP should be individually titrated using oesophageal pressure as a surrogate of pleural pressure rather than relying on an empirical high-PEEP FiO2 table. The randomised trial included patients with moderate-to-severe ARDS and compared an oesophageal-pressure-guided strategy with a conventional approach. The primary composite outcome, incorporating death and days free from mechanical ventilation through day 28, did not differ significantly between groups. The study is important because it tested a physiologically appealing form of personalised ventilation under rigorous clinical conditions. Oesophageal pressure can help estimate transpulmonary pressure and may be useful in selected patients with altered chest-wall mechanics, obesity or unusual respiratory-system behaviour. However, the trial shows that a plausible physiological signal does not automatically translate into better outcomes when used as the basis for a treatment algorithm across a heterogeneous population. For clinicians, the message is not that advanced respiratory mechanics are useless, but that they should complement rather than replace broader assessment of recruitability, compliance, haemodynamics and disease phenotype. EPVent-2 is therefore a useful caution against assuming that every available measurement needs to become a treatment target. Personalisation works best when the measurement is reliable, the biological mechanism is relevant and the intervention meaningfully changes management.
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EPVent-2 evaluated whether PEEP should be individually titrated using oesophageal pressure as a surrogate of pleural pressure rather than relying on an empirical high-PEEP FiO2 table. The randomised trial included patients with moderate-to-severe ARDS and compared an oesophageal-pressure-guided strategy with a conventional approach. The primary composite outcome, incorporating death and days free from mechanical ventilation through day 28, did not differ significantly between groups. The study is important because it tested a physiologically appealing form of personalised ventilation under rigorous clinical conditions. Oesophageal pressure can help estimate transpulmonary pressure and may be useful in selected patients with altered chest-wall mechanics, obesity or unusual respiratory-system behaviour. However, the trial shows that a plausible physiological signal does not automatically translate into better outcomes when used as the basis for a treatment algorithm across a heterogeneous population. For clinicians, the message is not that advanced respiratory mechanics are useless, but that they should complement rather than replace broader assessment of recruitability, compliance, haemodynamics and disease phenotype. EPVent-2 is therefore a useful caution against assuming that every available measurement needs to become a treatment target. Personalisation works best when the measurement is reliable, the biological mechanism is relevant and the intervention meaningfully changes management.
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