Background Traditional approaches to mechanical ventilationuse tidal volumes of 10 to 15 ml per kilogram of body weightand may cause stretch-induced lung injury in patients with acutelung injury and the acute respiratory distress syndrome. Wetherefore conducted a trial to determine whether ventilationwith lower tidal volumes would improve the clinical outcomesin these patients.
Methods Patients with acute lung injury and the acute respiratorydistress syndrome were enrolled in a multicenter, randomizedtrial. The trial compared traditional ventilation treatment,which involved an initial tidal volume of 12 ml per kilogramof predicted body weight and an airway pressure measured aftera 0.5-second pause at the end of inspiration (plateau pressure)of 50 cm of water or less, with ventilation with a lower tidalvolume, which involved an initial tidal volume of 6 ml per kilogramof predicted body weight and a plateau pressure of 30 cm ofwater or less. The first primary outcome was death before apatient was discharged home and was breathing without assistance.The second primary outcome was the number of days without ventilatoruse from day 1 to day 28.
Results The trial was stopped after the enrollment of 861 patientsbecause mortality was lower in the group treated with lowertidal volumes than in the group treated with traditional tidalvolumes (31.0 percent vs. 39.8 percent, P=0.007), and the numberof days without ventilator use during the first 28 days afterrandomization was greater in this group (mean [±SD],12±11 vs. 10±11; P=0.007). The mean tidal volumeson days 1 to 3 were 6.2±0.8 and 11.8±0.8 ml perkilogram of predicted body weight (P<0.001), respectively,and the mean plateau pressures were 25±6 and 33±8cm of water (P<0.001), respectively.
Conclusions In patients with acute lung injury and the acuterespiratory distress syndrome, mechanical ventilation with alower tidal volume than is traditionally used results in decreasedmortality and increases the number of days without ventilatoruse.
Source Information
The writing committee (Roy G. Brower, M.D., Johns Hopkins University, Baltimore; Michael A. Matthay, M.D., University of California, San Francisco; Alan Morris, M.D., LDS Hospital, Salt Lake City; David Schoenfeld, Ph.D., and B. Taylor Thompson, M.D., Massachusetts General Hospital, Boston; and Arthur Wheeler, M.D., Vanderbilt University, Nashville) assumes responsibility for the overall content and integrity of the manuscript. Presented in part at the International Conference of the American Lung Association and the American Thoracic Society, San Diego, Calif., April 26, 1999.
Address reprint requests to Dr. Brower at the Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 600 N. Wolfe St., Baltimore, MD 21287.
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