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A 65-year-old man in cardiogenic shock with copious pulmonary edema could not be ventilated despite paralysis and was placed on venoarterial-extracorporeal membrane oxygenation. Initial ventilator settings were pressure control ventilation 10 cm H 2 O, positive end-expiratory pressure 20 cm H 2 O, and respiratory rate 15 breaths per minute. Both V t and V. e were negligible.

An esophageal balloon showed high esophageal pressure (35 cm H 2 O) and negative values of transpulmonary pressure (estimated as airway pressure− esophageal pressure)(1, 2) during the entire respiratory cycle (from− 16 to− 6 cm H 2 O). To obtain a continuous visualization of ventilation during a lung recruitment maneuver, an electrical impedance tomography belt was applied around the patient’s chest (3). Interestingly, air started to enter in the lungs when airway pressure overcame esophageal pressure (airway pressure> 35 cm H …