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Cited by 1,370Respiratory Support and MechanismsNeonatal Respiratory Health ResearchNosocomial Infections in ICU

Ventilation Strategy Using Low Tidal Volumes, Recruitment Maneuvers, and High Positive End-Expiratory Pressure for Acute Lung Injury and Acute Respiratory Distress Syndrome: A Randomized Controlled Trial

Meade, Maureen O., Cook, Deborah J., Guyatt, Gordon H., Slutsky, Arthur S., Arabi, Yaseen M., Cooper, D. James, Davies, Andrew R., Hand, Lori E. +10 more·2008·JAMA
DOI 10.1001/jama.299.6.637
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Abstract

CONTEXT: Low-tidal-volume ventilation reduces mortality in critically ill patients with acute lung injury and acute respiratory distress syndrome. Instituting additional strategies to open collapsed lung tissue may further reduce mortality. OBJECTIVE: To compare an established low-tidal-volume ventilation strategy with an experimental strategy based on the original "open-lung approach," combining low tidal volume, lung recruitment maneuvers, and high positive-end-expiratory pressure. DESIGN AND SETTING: Randomized controlled trial with concealed allocation and blinded data analysis conducted between August 2000 and March 2006 in 30 intensive care units in Canada, Australia, and Saudi Arabia. PATIENTS: Nine hundred eighty-three consecutive patients with acute lung injury and a ratio of arterial oxygen tension to inspired oxygen fraction not exceeding 250. INTERVENTIONS: The control strategy included target tidal volumes of 6 mL/kg of predicted body weight, plateau airway pressures not exceeding 30 cm H2O, and conventional levels of positive end-expiratory pressure (n = 508). The experimental strategy included target tidal volumes of 6 mL/kg of predicted body weight, plateau pressures not exceeding 40 cm H2O, recruitment maneuvers, and higher positive end-expiratory pressures (n = 475). MAIN OUTCOME MEASURE: All-cause hospital mortality. RESULTS: Eighty-five percent of the 983 study patients met criteria for acute respiratory distress syndrome at enrollment. Tidal volumes remained similar in the 2 groups, and mean positive end-expiratory pressures were 14.6 (SD, 3.4) cm H2O in the experimental group vs 9.8 (SD, 2.7) cm H2O among controls during the first 72 hours (P < .001). All-cause hospital mortality rates were 36.4% and 40.4%, respectively (relative risk [RR], 0.90; 95% confidence interval [CI], 0.77-1.05; P = .19). Barotrauma rates were 11.2% and 9.1% (RR, 1.21; 95% CI, 0.83-1.75; P = .33). The experimental group had lower rates of refractory hypoxemia (4.6% vs 10.2%; RR, 0.54; 95% CI, 0.34-0.86; P = .01), death with refractory hypoxemia (4.2% vs 8.9%; RR, 0.56; 95% CI, 0.34-0.93; P = .03), and previously defined eligible use of rescue therapies (5.1% vs 9.3%; RR, 0.61; 95% CI, 0.38-0.99; P = .045). CONCLUSIONS: For patients with acute lung injury and acute respiratory distress syndrome, a multifaceted protocolized ventilation strategy designed to recruit and open the lung resulted in no significant difference in all-cause hospital mortality or barotrauma compared with an established low-tidal-volume protocolized ventilation strategy. This "open-lung" strategy did appear to improve secondary end points related to hypoxemia and use of rescue therapies. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00182195.

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  • A patient-level analysis of two of the randomised PEEP trials suggested that patients with ARDS who respond to increased PEEP with improved oxygenation have a lower risk of death; this association was stronger in patients with more severe ARDS (PaO2/FiO2 < 150 mmHg) compared with patients with less severe ARDS.

    “A patient-level analysis of two of the randomised PEEP trials [440, 441] suggested that patients with ARDS who respond to increased PEEP with improved oxygenation have a lower risk of death; this association was stronger in patients with more severe ARDS (PaO2/FiO2 < 150 mmHg) compared with patients with less severe ARDS [444].”

    From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [440]

  • We included three multicentre RCTs and one pilot RCT investigating use of higher PEEP versus lower PEEP strategies in conjunction with low tidal volumes for the management of patients with ARDS.

    “We included three multicentre RCTs [439–441] and one pilot RCT [442], investigating use of higher PEEP versus lower PEEP strategies in conjunction with low tidal volumes for the management of patients with ARDS.”

    From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [440]

  • A third option is to use a PEEP/FiO2 titration table that titrates PEEP based on the combination of FiO2 and PEEP required to maintain adequate oxygenation.

    “A third option is to use a PEEP/FiO2 titration table that titrates PEEP based on the combination of FiO2 and PEEP required to maintain adequate oxygenation [439–441].”

    From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [440]

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Authors
Meade, M. O., Cook, D. J., Guyatt, G. H., Slutsky, A. S., Arabi, Y. M., Cooper, D. J., Davies, A. R., Hand, L. E., Zhou, Q., Thabane, L., Austin, P., Lapinsky, S., Baxter, A., Russell, J., Skrobik, Y., Ronco, J. J., Stewart, T. E., & Lung Open Ventilation Study Investigators, F. T.
Affiliations
  • McMaster University (CA)
  • University of Toronto (CA)
  • King Abdulaziz University (SA)
  • The Alfred Hospital (AU)
  • University of Ottawa (CA)
  • University of British Columbia (CA)
  • Université de Montréal (CA)
Corresponding author
Meade, Maureen O.
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2008-02-13
Volume
299
Issue
6
Pages
637
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.299.6.637
OpenAlex
W2120076396
Cited by
1,370
References
22
Citations by year
2026: 34 · 2025: 41 · 2024: 51 · 2023: 52 · 2022: 81 · 2021: 86 · 2020: 59 · 2019: 63 · 2018: 78 · 2017: 90 · 2016: 69 · 2015: 91 · 2014: 97 · 2013: 90 · 2012: 92
FWCI
90.39
Type
journal article
Language
en
Open access
closed
Locations
  • JAMA (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Respiratory Support and Mechanisms
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Neonatal Respiratory Health Research
  • Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Nosocomial Infections in ICU
Keywords
acute lung injury, acute respiratory distress syndrome, low tidal volume ventilation, lung recruitment maneuver, positive end-expiratory pressure, open lung approach, mechanical ventilation, in-hospital mortality, barotrauma, refractory hypoxemia, lung-protective ventilation, PaO2/FiO2 ratio, critically ill patients, intensive care unit patients, randomized trial comparison
MeSH terms
Adult, Aged, Female, Humans, Male, Middle Aged, Positive-Pressure Respiration, Respiratory Distress Syndrome, Severity of Illness Index, Tidal Volume, Survival Analysis, Hospital Mortality

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