Background In patients with the acute respiratory distress syndrome,massive alveolar collapse and cyclic lung reopening and overdistentionduring mechanical ventilation may perpetuate alveolar injury.We determined whether a ventilatory strategy designed to minimizesuch lung injuries could reduce not only pulmonary complicationsbut also mortality at 28 days in patients with the acute respiratorydistress syndrome.
Methods We randomly assigned 53 patients with early acute respiratorydistress syndrome (including 28 described previously), all ofwhom were receiving identical hemodynamic and general support,to conventional or protective mechanical ventilation. Conventionalventilation was based on the strategy of maintaining the lowestpositive end-expiratory pressure (PEEP) for acceptable oxygenation,with a tidal volume of 12 ml per kilogram of body weight andnormal arterial carbon dioxide levels (35 to 38 mm Hg). Protectiveventilation involved end-expiratory pressures above the lowerinflection point on the static pressure–volume curve,a tidal volume of less than 6 ml per kilogram, driving pressuresof less than 20 cm of water above the PEEP value, permissivehypercapnia, and preferential use of pressure-limited ventilatorymodes.
Results After 28 days, 11 of 29 patients (38 percent) in theprotective-ventilation group had died, as compared with 17 of24 (71 percent) in the conventional-ventilation group (P<0.001).The rates of weaning from mechanical ventilation were 66 percentin the protective-ventilation group and 29 percent in the conventional-ventilationgroup (P = 0.005); the rates of clinical barotrauma were 7 percentand 42 percent, respectively (P = 0.02), despite the use ofhigher PEEP and mean airway pressures in the protective-ventilationgroup. The difference in survival to hospital discharge wasnot significant; 13 of 29 patients (45 percent) in the protective-ventilationgroup died in the hospital, as compared with 17 of 24 in theconventional-ventilation group (71 percent, P = 0.37).
Conclusions As compared with conventional ventilation, the protectivestrategy was associated with improved survival at 28 days, ahigher rate of weaning from mechanical ventilation, and a lowerrate of barotrauma in patients with the acute respiratory distresssyndrome. Protective ventilation was not associated with a higherrate of survival to hospital discharge.
Source Information
From the Respiratory Intensive Care Unit, Pulmonary Division, Hospital das Clínicas, University of São Paulo (M.B.P.A., C.S.V.B., D.M.M., R.B.M., G.P.P.S., G.L.-F., R.A.K., D.D., T.Y.T., C.R.R.C.); and the General Intensive Care Unit, Santa Casa de Misericórdia, Porto Alegre (C.M., R.O.) — both in Brazil. Presented in part at the International Conference of the American Lung Association and the American Thoracic Society, New Orleans, May 10–15, 1996.
Address reprint requests to Dr. Amato at 135 Rua Dr. Joel Lagos, CEP 05344-000 São Paulo, Brazil.
Protective Ventilation for the Acute Respiratory Distress Syndrome
Chiche J.-D., Brunet F., Lamy M., Kacmarek R., Parsons P. E., Matthay M., Manning H. L., Shapira M. Y., Sviri S., Linton D. M., Weg J. G., Anzueto A., Amato M. B.P., Barbas C. S.V., Carvalho C. R.R., Stewart T. E., Meade M. O., Slutsky A. S.
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N Engl J Med 1998;
339:196-199, Jul 16, 1998.
Correspondence
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