volumes (10 mL/kg) compared with those ventilated with low tidal volumes (6 mL/kg) [66, 67] . So it should not be surprising, although it may be very diffi cult to prove, that the employment of traditional tidal volumes in patients with IPF exacerbations would be detrimental given that their lungs are characterized by extended parenchymal alterations, severe inhomogeneity, and decreased compliance even prior to initiation of mechanical ventilation. Especially the inhomogeneity of the lung parenchyma could cause severe overinfl ation of the 'healthy' lung units with higher compliance and jeopardize the 'healthy' parenchyma left. A ventilation strategy employing low tidal volumes (4 to 6 mL/kg ideal body weight), such as that used for patients with ARDS, seems prudent and is advised by many experts [68] . Positive end-expiratory pressure (PEEP) should be used moderately because of the aforementioned risk of overinfl ation of intact lung units. Fernández-Pérez and colleagues [64] demonstrated that high PEEP was independently associated with increased mortality in chronic ILD [64] . In the same context, there is no place for recruitment or prone position [69] . Given that intubated patients with IPF exacerbations require high-minute volume because of increased dead space, the respiratory frequency should be increased to the maximum acceptable rate and the target of a normal PaCO 2 (arterial partial pressure of carbon dioxide) should be abandoned. Th is high respiratory rate might require the use of heavy sedation and quite often paralysis, and care should be given to avoid auto-PEEP [70] . Th e eff ect of prolonged sedation and paralysis on the neuromuscular function of these patients, who have often been administered steroids for a long time, is an unavoidable cost. Th e earliest possible interruption of sedation will facilitate weaning provided that gas exchange and lung mechanics have improved.