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Cited by 12,941Respiratory Support and MechanismsNeonatal Respiratory Health ResearchNosocomial Infections in ICU

Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome

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The Acute Respiratory Distress Syndrome Network·2000·New England Journal of Medicine
DOI 10.1056/nejm200005043421801
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Abstract

BACKGROUND: Traditional approaches to mechanical ventilation use tidal volumes of 10 to 15 ml per kilogram of body weight and may cause stretch-induced lung injury in patients with acute lung injury and the acute respiratory distress syndrome. We therefore conducted a trial to determine whether ventilation with lower tidal volumes would improve the clinical outcomes in these patients. METHODS: Patients with acute lung injury and the acute respiratory distress syndrome were enrolled in a multicenter, randomized trial. The trial compared traditional ventilation treatment, which involved an initial tidal volume of 12 ml per kilogram of predicted body weight and an airway pressure measured after a 0.5-second pause at the end of inspiration (plateau pressure) of 50 cm of water or less, with ventilation with a lower tidal volume, which involved an initial tidal volume of 6 ml per kilogram of predicted body weight and a plateau pressure of 30 cm of water or less. The primary outcomes were death before a patient was discharged home and was breathing without assistance and the number of days without ventilator use from day 1 to day 28. RESULTS: The trial was stopped after the enrollment of 861 patients because mortality was lower in the group treated with lower tidal volumes than in the group treated with traditional tidal volumes (31.0 percent vs. 39.8 percent, P=0.007), and the number of days without ventilator use during the first 28 days after randomization was greater in this group (mean [+/-SD], 12+/-11 vs. 10+/-11; P=0.007). The mean tidal volumes on days 1 to 3 were 6.2+/-0.8 and 11.8+/-0.8 ml per kilogram of predicted body weight (P<0.001), respectively, and the mean plateau pressures were 25+/-6 and 33+/-8 cm of water (P<0.001), respectively. CONCLUSIONS: In patients with acute lung injury and the acute respiratory distress syndrome, mechanical ventilation with a lower tidal volume than is traditionally used results in decreased mortality and increases the number of days without ventilator use.

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  • The 3 RCTs that guide the plateau pressure recommendation enrolled patients using the American-European Consensus Criteria Definition for Acute Lung Injury and ARDS, whereas the current document uses the 2012 Berlin definition.

    “Of note, the 3 RCTs that guide this recommendation [424, 426, 427] enrolled patients using the criteria from the American-European Consensus Criteria Definition for Acute Lung Injury and ARDS [422] whereas the current document use the 2012 Berlin definition and the terms mild, moderate, and severe ARDS (PaO2/FiO2 ≤ 300, ≤ 200, and ≤ 100 mm Hg, respectively) [423].”

    From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [424]

  • Several multicentre RCTs have been performed in patients with established ARDS to evaluate the effects of limiting inspiratory pressure through moderation of tidal volume.

    “Several multicentre RCTs have been performed in patients with established ARDS to evaluate the effects of limiting inspiratory pressure through moderation of tidal volume [424–427].”

    From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [424]

  • The largest trial of a volume- and pressure-limited strategy showed a 9% absolute decrease in mortality in ARDS patients ventilated with tidal volumes of 6 mL/kg compared with 12 mL/kg predicted body weight, and aiming for plateau pressure ≤ 30 cm H2O.

    “The largest trial of a volume- and pressure-limited strategy showed 9% absolute decrease in mortality in ARDS patients ventilated with tidal volumes of 6 mL/kg compared with 12 mL/ kg predicted body weight (PBW), and aiming for plateau pressure ≤ 30 cm H2O [424].”

    From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [424]

  • These studies showed differing results, which may have been caused by differences in airway pressures in the treatment and control groups.

    “These studies showed differing results, which may have been caused by differences in airway pressures in the treatment and control groups [423, 424, 428].”

    From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [424]

  • These three RCTs compared a strategy of low tidal volume and limited plateau pressure with a strategy using higher tidal volume and plateau pressure; pooled data suggest reduced mortality (RR 0.83; 95% CI 0.70-0.97) and more ventilator-free days (MD 1.8 days; 95% CI 0.35-3.25) in patients managed with low plateau pressures.

    “These three RCTS compared a strategy of low tidal volume and limited plateau pressure with a strategy using higher tidal volume and plateau pressure; pooled data suggest reduced mortality (RR 0.83; 95% CI 0.70–0.97) and more ventilator-free days (MD 1.8 days; 95% CI 0.35–3.25) in patients managed with low plateau pressures.”

    From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [424]

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Authors
The Acute Respiratory Distress Syndrome Network
Corresponding author
The Acute Respiratory Distress Syndrome Network
Venue
New England Journal of Medicine
Publisher
Massachusetts Medical Society
Published
2000-05-04
Volume
342
Issue
18
Pages
1301-1308
ISSN
  • 0028-4793 (ISSN-L)
  • 1533-4406
DOI
10.1056/nejm200005043421801
OpenAlex
W2597070792
Cited by
12,941
References
45
Citations by year
2026: 335 · 2025: 375 · 2024: 482 · 2023: 516 · 2022: 642 · 2021: 682 · 2020: 685 · 2019: 688 · 2018: 532 · 2017: 565 · 2016: 601 · 2015: 524 · 2014: 530 · 2013: 502 · 2012: 526
FWCI
246.12
Type
journal article
Language
en
Open access
Locations
  • New England Journal of Medicine (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • U.S. Department of Veterans Affairs
  • Massachusetts General Hospital
  • Vanderbilt University
  • University of Pennsylvania
  • University of Washington
  • Johns Hopkins University
  • Kementerian Pendidikan Nasional
  • National Institutes of Health (n01hr046056-006, n01hr046055-006, n01hr046054-006)
  • University of California, San Francisco
  • National Heart, Lung, and Blood Institute (N01-HR-46054, N01-HR 46056, N0-1 HR 46055)
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
low tidal volume ventilation, acute lung injury, acute respiratory distress syndrome, mechanical ventilation, plateau pressure, mortality, weaning from mechanical ventilation, lung-protective ventilation
MeSH terms
Barotrauma, Female, Humans, Male, Middle Aged, Positive-Pressure Respiration, Respiration, Artificial, Respiratory Distress Syndrome, Tidal Volume, Survival Analysis, Lung Injury

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