Peak vs Plateau Pressure: Guide for Nurses & RTs

Understanding respiratory mechanics is critical for healthcare professionals, particularly when managing mechanically ventilated patients, and this understanding hinges on differentiating peak pressure from plateau pressure. Peak inspiratory pressure (PIP), measured during mechanical ventilation, represents the total pressure needed to deliver a breath, including both the pressure to overcome airway resistance and the pressure to inflate the alveoli. Plateau pressure, on the other hand, is measured after a short inspiratory pause, reflecting the pressure in the alveoli and small airways, essentially indicating the distending pressure on the lung. Respiratory therapists (RTs) utilize these measurements to assess lung compliance and resistance, crucial elements in setting appropriate ventilator parameters to prevent lung injury; high plateau pressures may indicate Acute Respiratory Distress Syndrome (ARDS) or overdistension, conditions that nurses monitor closely. The relationship between peak vs plateau pressure serves as a guide to understanding the patient’s respiratory status and the effectiveness of ventilator support.

Mechanical ventilation is a critical intervention in modern healthcare, serving as a life-sustaining procedure for patients unable to maintain adequate respiratory function. This section lays the groundwork for understanding its purpose, objectives, and the pivotal role of pressure monitoring in ensuring patient safety and optimizing respiratory support.

Defining Mechanical Ventilation

At its core, mechanical ventilation is a method of assisting or completely replacing spontaneous breathing. It involves using a mechanical ventilator to deliver breaths to the patient, providing the necessary respiratory support when the patient's own respiratory system is compromised. This intervention can be life-saving in scenarios where the patient's respiratory muscles are weak, the lungs are damaged, or the drive to breathe is impaired.

Primary Goals of Mechanical Ventilation

The overarching goals of mechanical ventilation can be summarized into three primary objectives:

• Supporting Gas Exchange: The ventilator facilitates the exchange of oxygen and carbon dioxide, ensuring adequate oxygenation of the blood and the removal of carbon dioxide. This support is crucial in conditions where the lungs are unable to perform this function effectively.

• Reducing the Work of Breathing: By providing mechanical assistance, the ventilator alleviates the burden on the patient's respiratory muscles. This reduction in effort allows the patient to conserve energy and focus on recovery.

• Allowing the Lungs to Heal: In cases of lung injury or disease, mechanical ventilation provides a supportive environment that allows the lungs to rest and recover. This is particularly important in conditions such as pneumonia or acute respiratory distress syndrome (ARDS).

The Importance of Pressure Monitoring

Effective mechanical ventilation hinges on careful pressure management. Monitoring key pressure parameters is essential for optimizing ventilatory support and preventing ventilator-induced lung injury (VILI). Excessive pressures can lead to barotrauma or volutrauma, causing further damage to the lungs. Conversely, insufficient pressures may result in inadequate ventilation and oxygenation.

Key Pressure Measurements: PIP and Pplat

Two key pressure measurements that guide ventilator management are Peak Inspiratory Pressure (PIP) and Plateau Pressure (Pplat).

• Peak Inspiratory Pressure (PIP) is the maximum pressure measured during inspiration and reflects the combined resistance of the airways and the stiffness of the lungs.

• Plateau Pressure (Pplat), measured during a brief inspiratory pause, provides an estimate of the alveolar pressure and is an indicator of lung compliance.

Understanding and interpreting these pressures is fundamental for nurses and respiratory therapists (RTs) to ensure optimal ventilator settings and minimize the risk of lung injury.

Mechanical ventilation is a critical intervention in modern healthcare, serving as a life-sustaining procedure for patients unable to maintain adequate respiratory function. This section lays the groundwork for understanding its purpose, objectives, and the pivotal role of pressure monitoring in ensuring patient safety and optimizing respiratory support.

Understanding Key Physiological Concepts: Pressures, Resistance, and Compliance

Effective mechanical ventilation relies on a solid understanding of the fundamental physiological principles governing respiratory mechanics. These principles include the relationships between pressures, resistance, and compliance within the respiratory system.

Mastering these concepts enables nurses and respiratory therapists to interpret ventilator data accurately, make informed adjustments, and ultimately deliver optimal patient care.

Decoding Peak Inspiratory Pressure (PIP)

Peak Inspiratory Pressure (PIP) is the maximum pressure measured during the inspiratory phase of a mechanical breath.

It reflects the total pressure required to deliver a breath, encompassing the forces needed to overcome both airway resistance and the elastic recoil of the lungs and chest wall.

Clinical Significance of PIP

Clinically, PIP serves as a valuable indicator of the overall effort required to inflate the lungs.

An elevated PIP suggests an increase in either airway resistance, lung stiffness, or both.

Monitoring trends in PIP can alert clinicians to developing problems such as bronchospasm, mucus plugging, or worsening pulmonary edema.

Unveiling Plateau Pressure (Pplat)

Plateau Pressure (Pplat) represents the pressure within the alveoli during a brief inspiratory pause, typically 0.5 to 1 second.

This pause eliminates the influence of airway resistance, providing a more accurate reflection of alveolar pressure.

Clinical Significance of Pplat

Pplat serves as a crucial indicator of lung compliance. It directly reflects the pressure exerted on the alveoli.

An elevated Pplat suggests decreased lung compliance, indicating stiffer lungs and an increased risk of ventilator-induced lung injury (VILI).

Maintaining Pplat within safe limits (typically <30 cm H2O) is a cornerstone of lung-protective ventilation strategies.

Airway Resistance (Raw)

Airway Resistance (Raw) is the opposition to airflow within the airways.

It is determined by the diameter of the airways, the length of the airways, and the viscosity of the gas flowing through them. Clinically, Raw is increased in situations such as bronchospasm and mucus plugging.

Factors Influencing Airway Resistance

Several factors can influence airway resistance. Bronchospasm, the constriction of smooth muscle in the airways, significantly narrows the airway lumen, increasing resistance.

Secretions, such as mucus, can also obstruct airflow, particularly in patients with pneumonia or chronic bronchitis.

The size of the endotracheal tube plays a role; smaller tubes create higher resistance.

Kinking or obstruction of the endotracheal tube itself will also increase resistance.

Understanding Lung Compliance (C)

Lung Compliance (C) is a measure of the lung's ability to stretch and expand in response to applied pressure. It's defined as the change in volume (ΔVolume) per unit change in pressure (ΔPressure): C = ΔV/ΔP.

Clinical Significance of Lung Compliance

Reduced lung compliance indicates stiffer lungs, requiring higher pressures to achieve adequate ventilation. Conditions such as ARDS, pulmonary fibrosis, and pneumonia can decrease lung compliance.

Conversely, increased lung compliance, while seemingly beneficial, can sometimes be seen in conditions like emphysema, where the lungs have lost their elastic recoil.

Static vs. Dynamic Compliance: A Crucial Distinction

It is important to differentiate between static and dynamic compliance, as each provides distinct clinical information.

Static Compliance

Static compliance is measured when there is no airflow, typically during the inspiratory pause used to measure Pplat.

It is calculated using the formula: Static Compliance = Tidal Volume / (Pplat - PEEP). Static compliance primarily reflects the elastic properties of the lung parenchyma.

Dynamic Compliance

Dynamic compliance is measured while gas is flowing during inspiration.

It is calculated using the formula: Dynamic Compliance = Tidal Volume / (PIP - PEEP). Dynamic compliance is influenced by both the elastic properties of the lungs and the resistance of the airways.

A decrease in dynamic compliance with stable static compliance suggests increased airway resistance. A decrease in both suggests a change in lung compliance itself.

The Role of Tidal Volume (Vt)

Tidal Volume (Vt) refers to the volume of air delivered with each mechanical breath.

It is a key parameter in ventilator management, directly influencing minute ventilation (the total volume of gas inhaled or exhaled per minute).

Appropriate tidal volume settings are crucial for maintaining adequate gas exchange and preventing both under-ventilation and over-distension of the alveoli.

Selecting the ideal tidal volume is often based on the patient's ideal body weight (IBW) and the underlying lung condition.

Patient Safety and Troubleshooting: Preventing Ventilator-Induced Lung Injury (VILI)

Mechanical ventilation, while life-saving, carries the inherent risk of ventilator-induced lung injury (VILI). VILI encompasses a spectrum of lung damage caused by the mechanical ventilator itself.

Diligent monitoring of peak inspiratory pressure (PIP) and plateau pressure (Pplat) is paramount in mitigating this risk. Recognizing deviations from acceptable pressure ranges and implementing timely corrective actions are crucial for safeguarding patients.

This section will delve into strategies for identifying and troubleshooting elevated pressures, ensuring the delivery of safe and effective mechanical ventilation.

The Critical Role of Pressure Monitoring in VILI Prevention

Continuous vigilance in monitoring PIP and Pplat allows clinicians to detect early signs of respiratory compromise and potential lung injury.

Sustained elevation of either pressure parameter warrants prompt investigation and intervention. Understanding the underlying causes of elevated pressures is essential for implementing appropriate corrective measures.

Failing to address these issues can lead to VILI, which includes conditions such as barotrauma (lung injury due to excessive pressure), volutrauma (lung injury due to excessive volume), atelectrauma (lung injury due to repeated opening and closing of alveoli), and biotrauma (inflammatory response to mechanical ventilation).

Troubleshooting Elevated Peak Inspiratory Pressure (PIP)

An elevated PIP signifies increased resistance to airflow during inspiration.

Clinicians should systematically evaluate potential causes, beginning with the most common and readily addressable factors.

Assessing Airway Resistance

Increased airway resistance is a frequent culprit behind elevated PIP. Potential causes include:

• Secretions: Accumulated secretions in the airways can obstruct airflow. Suctioning the patient is often the first and most effective intervention.

• Bronchospasm: Constriction of the bronchial smooth muscle narrows the airways. Administering bronchodilators can help alleviate bronchospasm and reduce PIP.

• Endotracheal Tube Issues: Kinking, obstruction, or inappropriate size of the endotracheal tube can also contribute to increased resistance. Ensure the tube is patent and appropriately positioned.

Evaluating Equipment-Related Problems

The mechanical ventilator circuit and associated equipment are potential sources of increased PIP.

Thoroughly inspect the following:

• Kinked Tubing: Ensure the ventilator tubing is free of kinks or compression that may impede airflow.

• Water in the Circuit: Accumulated condensation within the tubing can increase resistance. Drain any excess water.

• Humidifier Settings: Inappropriate humidifier settings can lead to excessive condensation or contribute to increased airway resistance.

Troubleshooting Elevated Plateau Pressure (Pplat)

An elevated Pplat indicates decreased lung compliance, suggesting that the lungs are becoming stiffer and require higher pressures to inflate.

Addressing elevated Pplat is critical for preventing volutrauma and other forms of VILI.

Addressing Decreased Lung Compliance

Conditions that reduce lung compliance necessitate careful evaluation and management.

Common causes include:

• Acute Respiratory Distress Syndrome (ARDS): ARDS is characterized by widespread inflammation and fluid accumulation in the lungs. Lung-protective ventilation strategies with lower tidal volumes and judicious use of PEEP are essential.

• Pulmonary Edema: Fluid overload can lead to pulmonary edema, decreasing lung compliance. Diuretics may be necessary to reduce fluid volume.

• Pneumonia: Infections within the lung parenchyma can decrease lung compliance. Administer appropriate antibiotics.

Ruling Out Pneumothorax

Pneumothorax, or the presence of air in the pleural space, can significantly impair lung expansion and increase Pplat. A sudden increase in Pplat, especially if accompanied by unilateral decreased breath sounds and respiratory distress, should prompt immediate evaluation for pneumothorax.

A chest X-ray is essential for confirming the diagnosis. Treatment may involve needle aspiration or chest tube placement.

Interprofessional Collaboration and Evidence-Based Practice in Ventilation Management

Effective ventilation management extends far beyond individual expertise. It necessitates a cohesive, team-based approach where diverse healthcare professionals – nurses, respiratory therapists (RTs), and physicians – work synergistically.

The cornerstone of this collaboration is open and consistent communication.

Misunderstandings or lack of shared situational awareness can lead to suboptimal patient care and potentially adverse events. This section underscores how such a team effort is critical and will explore the ways in which evidence-based guidelines improve outcomes.

The Synergy of Teamwork: Enhancing Patient Outcomes

Interprofessional collaboration isn't merely a procedural formality; it's a vital strategy to improve patient outcomes. Each professional brings a unique perspective and skillset to the table.

RTs possess specialized knowledge of ventilator mechanics and respiratory physiology. Nurses provide continuous bedside monitoring and administer medications. Physicians oversee the overall treatment plan and make critical decisions.

When these disciplines communicate effectively, they can leverage their collective expertise to identify subtle changes in patient condition, anticipate potential complications, and tailor ventilation strategies accordingly. This coordinated approach leads to more timely and effective interventions, ultimately improving patient outcomes.

Evidence-Based Guidelines: The Foundation of Optimal Ventilation

Beyond teamwork, a commitment to evidence-based practice is paramount. Ventilation strategies should be grounded in the latest research and established clinical guidelines.

Relying solely on tradition or personal preference can lead to variations in care and potentially compromise patient safety.

Clinical guidelines, such as those published by professional organizations like the American Thoracic Society (ATS) and the Society of Critical Care Medicine (SCCM), provide a framework for best practices in ventilation management.

These guidelines are developed through rigorous systematic reviews of the literature and expert consensus, ensuring that clinical decisions are informed by the best available evidence. Implementing these guidelines reduces unwarranted variability and promotes consistent, high-quality care.

Staying Current: Continuous Professional Development

The field of mechanical ventilation is constantly evolving. New technologies, therapies, and research findings emerge regularly. Therefore, continuous professional development is not optional but essential.

Nurses, RTs, and physicians must actively engage in ongoing learning activities to stay updated with the latest advancements.

This can include attending conferences, participating in workshops, reading peer-reviewed journals, and completing continuing education courses. By investing in their professional development, clinicians can ensure they are equipped with the knowledge and skills necessary to provide optimal ventilation management and improve patient outcomes.

Ventilator Settings and Modes: Optimizing Respiratory Support

Mechanical ventilation demands a nuanced understanding of various settings and modes. These tools allow clinicians to tailor respiratory support, optimizing gas exchange while minimizing the risk of ventilator-induced lung injury (VILI). The selection and management of these settings are critical in achieving optimal patient outcomes.

Positive End-Expiratory Pressure (PEEP): Maintaining Alveolar Stability

PEEP is a crucial ventilator setting that maintains positive pressure in the airways at the end of exhalation.

This seemingly simple intervention has profound effects on respiratory physiology.

The Benefits of PEEP

The primary benefit of PEEP is the prevention of alveolar collapse. By maintaining a positive pressure, PEEP increases the functional residual capacity (FRC) and keeps alveoli open, thereby improving oxygenation.

This is particularly important in conditions like ARDS, where alveolar collapse is a significant contributor to hypoxemia.

PEEP can also reduce the work of breathing by improving lung compliance and reducing the inspiratory effort required to open collapsed alveoli.

Potential Adverse Effects of PEEP

While PEEP offers substantial benefits, it's not without potential risks. Excessive PEEP can lead to barotrauma, causing lung injury due to overdistension of alveoli.

Furthermore, high levels of PEEP can impede venous return, leading to decreased cardiac output and potentially compromising systemic oxygen delivery.

Careful titration of PEEP, guided by clinical assessment and physiological monitoring, is essential to maximize its benefits while minimizing the risks.

Volume-Controlled Ventilation: Ensuring Consistent Tidal Volume Delivery

Volume-controlled ventilation (VCV) is a mode in which a set tidal volume is delivered with each breath.

The pressure required to deliver the set volume varies depending on the patient's lung mechanics (compliance and resistance).

How Volume-Controlled Ventilation Works

In VCV, the ventilator guarantees a consistent tidal volume, irrespective of changes in the patient's respiratory system. This is advantageous in situations where maintaining a specific minute ventilation is crucial.

The disadvantage is that pressure is not limited, and with worsening lung compliance or increased airway resistance, peak and plateau pressures can rise to dangerous levels, increasing the risk of VILI.

Indications for Volume-Controlled Ventilation

VCV is often indicated in patients with relatively stable respiratory mechanics who require a guaranteed minute ventilation. Examples include patients with:

• Neuromuscular weakness

• Central hypoventilation syndromes

• Post-operative respiratory support

Close monitoring of airway pressures is crucial during VCV to prevent overdistension and lung injury.

Pressure-Controlled Ventilation: Limiting Airway Pressure

Pressure-controlled ventilation (PCV) is a mode in which a set pressure is delivered during each breath.

The tidal volume delivered varies depending on the patient's lung mechanics.

How Pressure-Controlled Ventilation Works

In PCV, the clinician sets a target inspiratory pressure, and the ventilator delivers and maintains that pressure for a specified inspiratory time. The tidal volume achieved depends on the patient's lung compliance and resistance.

PCV offers the advantage of limiting peak airway pressures, which can be beneficial in patients at high risk for VILI. The disadvantage is that tidal volume is not guaranteed, and with worsening lung compliance or increased airway resistance, hypoventilation can occur.

Indications for Pressure-Controlled Ventilation

PCV is often considered in patients with:

• ARDS

• Other conditions where limiting peak airway pressures is desirable.

While PCV can help reduce the risk of barotrauma, it requires careful monitoring of tidal volumes and minute ventilation to ensure adequate gas exchange.

Clinical Conditions Affecting Pressure and Ventilation: ARDS and Auto-PEEP

Mechanical ventilation is often complicated by underlying pulmonary pathologies that significantly impact pressure dynamics and ventilation strategies. Successfully managing these conditions requires a deep understanding of their pathophysiology and tailored approaches to mitigate their effects on respiratory mechanics. Two critical conditions that profoundly affect pressure and ventilation are Acute Respiratory Distress Syndrome (ARDS) and Auto-PEEP (intrinsic PEEP).

Acute Respiratory Distress Syndrome (ARDS): A Landscape of Inflammatory Lung Injury

ARDS represents a severe form of acute lung injury characterized by widespread inflammation and increased permeability of the alveolar-capillary membrane.

This leads to the accumulation of protein-rich fluid in the alveoli and interstitial spaces, resulting in pulmonary edema, impaired gas exchange, and decreased lung compliance.

Pathophysiology of ARDS

The pathogenesis of ARDS involves a complex interplay of inflammatory mediators, endothelial and epithelial cell damage, and surfactant dysfunction.

Initiating events, such as sepsis, pneumonia, or trauma, trigger an uncontrolled inflammatory response in the lungs.

This response leads to the release of cytokines and other inflammatory substances, causing increased vascular permeability and alveolar flooding.

The resulting hyaline membrane formation and alveolar collapse further contribute to the hallmark features of ARDS: hypoxemia and reduced lung compliance.

Ventilation Strategies in ARDS: Lung-Protective Ventilation

Given the fragile state of the ARDS-affected lung, ventilation strategies focus on minimizing further lung injury while optimizing gas exchange.

Lung-protective ventilation (LPV) is the cornerstone of ARDS management.

LPV emphasizes the use of low tidal volumes (4-8 mL/kg of predicted body weight) to prevent overdistension of alveoli, a phenomenon known as volutrauma.

In addition to low tidal volumes, appropriate levels of Positive End-Expiratory Pressure (PEEP) are crucial to maintain alveolar patency and improve oxygenation.

PEEP helps prevent alveolar collapse, increases functional residual capacity (FRC), and redistributes lung water.

The optimal level of PEEP is determined by balancing the benefits of improved oxygenation against the risk of overdistension and decreased cardiac output.

Frequent monitoring of plateau pressure is essential to ensure that alveolar pressure remains within safe limits (typically <30 cm H2O) to minimize the risk of ventilator-induced lung injury (VILI).

Auto-PEEP (Intrinsic PEEP): The Hidden Threat

Auto-PEEP, also known as intrinsic PEEP, refers to the unintentional positive pressure that remains in the lungs at the end of exhalation due to incomplete emptying of the alveoli.

This phenomenon occurs when the expiratory time is insufficient to allow the lungs to fully deflate before the next breath is initiated.

Causes of Auto-PEEP

Several factors can contribute to the development of Auto-PEEP:

• Increased respiratory rate: Shorter expiratory time

• Increased airway resistance: COPD, asthma, or secretions

• Reduced expiratory flow: Weak respiratory muscles

• High minute ventilation: Insufficient time for exhalation

Patients with obstructive lung diseases, such as COPD and asthma, are particularly vulnerable to developing Auto-PEEP due to their increased airway resistance and prolonged expiratory time.

Mitigating Auto-PEEP: Strategies for Lung Emptying

Managing Auto-PEEP involves strategies aimed at promoting complete lung emptying and reducing air trapping:

• Decreasing respiratory rate: Lengthens expiratory time

• Increasing expiratory time: Adjusting I:E ratio

• Reducing minute ventilation: Carefully consider patient's needs

• Bronchodilators: Decrease airway resistance

• Optimizing ventilator settings: Tailored approach

In some cases, applying external PEEP can help mitigate the adverse effects of Auto-PEEP by splinting open the airways and reducing the pressure gradient required for the patient to initiate inspiration.

However, the application of external PEEP in the presence of Auto-PEEP requires careful monitoring to avoid overdistension and hemodynamic compromise. Regular assessment of expiratory flow waveforms can help identify the presence of Auto-PEEP and guide appropriate ventilator adjustments.

Equipment Utilized in Mechanical Ventilation: A Technical Overview

Mechanical ventilation relies on a complex interplay of sophisticated equipment to deliver life-sustaining respiratory support.

A comprehensive understanding of the components and functions of this equipment is paramount for nurses and respiratory therapists to ensure optimal patient care and safety.

This section provides a technical overview of the essential tools used in mechanical ventilation, including ventilators, circuits, and pressure manometers.

The Modern Mechanical Ventilator: A Symphony of Engineering

The mechanical ventilator is the centerpiece of respiratory support, acting as an artificial respiratory pump.

Modern ventilators are sophisticated machines capable of precisely controlling and monitoring various aspects of the respiratory cycle.

They feature a complex array of components that work in concert to deliver customized ventilatory support.

Key Components and Functions

At its core, a ventilator consists of a gas source, a microprocessor, a control panel, and a delivery system.

The gas source provides a blend of oxygen and air, carefully regulated to achieve the desired FiO2 (fraction of inspired oxygen).

The microprocessor serves as the brain of the ventilator, orchestrating the timing, volume, and pressure of each breath.

The control panel allows clinicians to set and adjust ventilator parameters, tailoring the support to the patient's specific needs.

The delivery system comprises valves, regulators, and tubing that precisely control the flow of gas to the patient.

Modern ventilators are equipped with advanced monitoring capabilities, providing real-time data on pressure, volume, flow, and respiratory mechanics.

These data are displayed on a screen, allowing clinicians to continuously assess the patient's response to ventilation and make necessary adjustments.

Ventilators offer a variety of modes, each designed to provide a different level of support.

Understanding these modes and their specific applications is crucial for effective ventilation management.

Ventilator Circuit: The Lifeline to the Patient's Airway

The ventilator circuit is the crucial connection between the ventilator and the patient's airway.

It is a system of tubing that delivers the controlled gas mixture from the ventilator to the patient's lungs and facilitates the exhalation of carbon dioxide.

The circuit typically consists of inspiratory and expiratory limbs, a wye connector, and humidification devices.

The inspiratory limb carries the gas from the ventilator to the patient's airway, while the expiratory limb returns the exhaled gas to the ventilator.

The wye connector serves as the point of connection to the patient's endotracheal tube or tracheostomy tube.

Humidification is essential to prevent drying of the airways.

Heated humidifiers or heat-moisture exchangers (HMEs) are commonly used to add moisture to the inspired gas.

The integrity of the ventilator circuit is paramount.

Leaks, disconnections, or obstructions can compromise ventilation and lead to adverse patient outcomes.

Regular inspection and maintenance of the circuit are essential for ensuring optimal performance and safety.

Pressure Manometer: Monitoring the Breath-by-Breath Dynamics

The pressure manometer is a vital tool for measuring pressure within the ventilator circuit.

It provides a continuous readout of airway pressures, allowing clinicians to assess the effectiveness of ventilation and detect potential problems.

The manometer displays several key pressure measurements, including Peak Inspiratory Pressure (PIP), Plateau Pressure (Pplat), and Positive End-Expiratory Pressure (PEEP).

PIP reflects the maximum pressure during inspiration, influenced by both airway resistance and lung compliance.

Pplat represents the alveolar pressure during a brief inspiratory pause, serving as an indicator of lung compliance.

PEEP is the pressure maintained in the airways at the end of exhalation, preventing alveolar collapse and improving oxygenation.

Monitoring pressure trends over time is crucial for identifying changes in respiratory mechanics and guiding ventilator adjustments.

Sudden increases in PIP or Pplat may indicate developing complications such as bronchospasm, secretions, or decreased lung compliance.

Careful interpretation of pressure readings, in conjunction with other clinical data, is essential for safe and effective ventilation management.

So, there you have it! Mastering the nuances of peak vs plateau pressure can feel like a juggling act at times, but with a solid understanding and consistent monitoring, you'll be well-equipped to keep your patients breathing easy. Keep practicing, stay curious, and don't hesitate to collaborate with your team. You got this!