Effect of a Protective-Ventilation Strategy on Mortality in the Acute Respiratory Distress Syndrome Export

@article{citeulike:2834807, abstract = {Background In patients with the acute respiratory distress syndrome, massive alveolar collapse and cyclic lung reopening and overdistention during mechanical ventilation may perpetuate alveolar injury. We determined whether a ventilatory strategy designed to minimize such lung injuries could reduce not only pulmonary complications but also mortality at 28 days in patients with the acute respiratory distress syndrome. Methods We randomly assigned 53 patients with early acute respiratory distress syndrome (including 28 described previously), all of whom were receiving identical hemodynamic and general support, to conventional or protective mechanical ventilation. Conventional ventilation was based on the strategy of maintaining the lowest positive end-expiratory pressure (PEEP) for acceptable oxygenation, with a tidal volume of 12 ml per kilogram of body weight and normal arterial carbon dioxide levels (35 to 38 mm Hg). Protective ventilation involved end-expiratory pressures above the lower inflection point on the static pressure-volume curve, a tidal volume of less than 6 ml per kilogram, driving pressures of less than 20 cm of water above the PEEP value, permissive hypercapnia, and preferential use of pressure-limited ventilatory modes. Results After 28 days, 11 of 29 patients (38 percent) in the protective-ventilation group had died, as compared with 17 of 24 (71 percent) in the conventional-ventilation group (P<0.001). The rates of weaning from mechanical ventilation were 66 percent in the protective-ventilation group and 29 percent in the conventional-ventilation group (P = 0.005); the rates of clinical barotrauma were 7 percent and 42 percent, respectively (P = 0.02), despite the use of higher PEEP and mean airway pressures in the protective-ventilation group. The difference in survival to hospital discharge was not significant; 13 of 29 patients (45 percent) in the protective-ventilation group died in the hospital, as compared with 17 of 24 in the conventional-ventilation group (71 percent, P = 0.37). Conclusions As compared with conventional ventilation, the protective strategy was associated with improved survival at 28 days, a higher rate of weaning from mechanical ventilation, and a lower rate of barotrauma in patients with the acute respiratory distress syndrome. Protective ventilation was not associated with a higher rate of survival to hospital discharge. 10.1056/NEJM199802053380602}, address = {Pulmonary Division, Hospital das Cl\'{\i}nicas, University of S\~{a}o Paulo, Brazil.}, author = {Amato, Marcelo B. and Barbas, Carmen S. and Medeiros, Denise M. and Magaldi, Ricardo B. and Schettino, Guilherme P. and Lorenzi-Filho, Geraldo and Kairalla, Ronaldo A. and Deheinzelin, Daniel and Munoz, Carlos and Oliveira, Roselaine and Takagaki, Teresa Y. and Carvalho, Carlos R.}, citeulike-article-id = {2834807}, citeulike-linkout-0 = {http://dx.doi.org/10.1056/NEJM199802053380602}, citeulike-linkout-1 = {http://content.nejm.org/cgi/content/abstract/338/6/347}, citeulike-linkout-2 = {http://view.ncbi.nlm.nih.gov/pubmed/9449727}, citeulike-linkout-3 = {http://www.hubmed.org/display.cgi?uids=9449727}, day = {5}, doi = {10.1056/NEJM199802053380602}, issn = {0028-4793}, journal = {N Engl J Med}, keywords = {mechanical-ventilation, open-lung, pulmorary, respiratory, ventilation}, month = {February}, number = {6}, pages = {347--354}, posted-at = {2009-04-30 16:24:58}, priority = {2}, title = {Effect of a Protective-Ventilation Strategy on Mortality in the Acute Respiratory Distress Syndrome}, url = {http://dx.doi.org/10.1056/NEJM199802053380602}, volume = {338}, year = {1998} }

TY - JOUR ID - citeulike:2834807 L3 - citeulike-article-id:2834807 N2 - Background In patients with the acute respiratory distress syndrome, massive alveolar collapse and cyclic lung reopening and overdistention during mechanical ventilation may perpetuate alveolar injury. We determined whether a ventilatory strategy designed to minimize such lung injuries could reduce not only pulmonary complications but also mortality at 28 days in patients with the acute respiratory distress syndrome. Methods We randomly assigned 53 patients with early acute respiratory distress syndrome (including 28 described previously), all of whom were receiving identical hemodynamic and general support, to conventional or protective mechanical ventilation. Conventional ventilation was based on the strategy of maintaining the lowest positive end-expiratory pressure (PEEP) for acceptable oxygenation, with a tidal volume of 12 ml per kilogram of body weight and normal arterial carbon dioxide levels (35 to 38 mm Hg). Protective ventilation involved end-expiratory pressures above the lower inflection point on the static pressure-volume curve, a tidal volume of less than 6 ml per kilogram, driving pressures of less than 20 cm of water above the PEEP value, permissive hypercapnia, and preferential use of pressure-limited ventilatory modes. Results After 28 days, 11 of 29 patients (38 percent) in the protective-ventilation group had died, as compared with 17 of 24 (71 percent) in the conventional-ventilation group (P<0.001). The rates of weaning from mechanical ventilation were 66 percent in the protective-ventilation group and 29 percent in the conventional-ventilation group (P = 0.005); the rates of clinical barotrauma were 7 percent and 42 percent, respectively (P = 0.02), despite the use of higher PEEP and mean airway pressures in the protective-ventilation group. The difference in survival to hospital discharge was not significant; 13 of 29 patients (45 percent) in the protective-ventilation group died in the hospital, as compared with 17 of 24 in the conventional-ventilation group (71 percent, P = 0.37). Conclusions As compared with conventional ventilation, the protective strategy was associated with improved survival at 28 days, a higher rate of weaning from mechanical ventilation, and a lower rate of barotrauma in patients with the acute respiratory distress syndrome. Protective ventilation was not associated with a higher rate of survival to hospital discharge. 10.1056/NEJM199802053380602 IS - 6 JF - N Engl J Med SN - 0028-4793 AD - Pulmonary Division, Hospital das Clínicas, University of São Paulo, Brazil. EP - 354 TI - Effect of a Protective-Ventilation Strategy on Mortality in the Acute Respiratory Distress Syndrome VL - 338 SP - 347 KW - mechanical-ventilation KW - open-lung KW - pulmorary KW - respiratory KW - ventilation AU - Amato, Marcelo AU - Barbas, Carmen AU - Medeiros, Denise AU - Magaldi, Ricardo AU - Schettino, Guilherme AU - Lorenzi-Filho, Geraldo AU - Kairalla, Ronaldo AU - Deheinzelin, Daniel AU - Munoz, Carlos AU - Oliveira, Roselaine AU - Takagaki, Teresa AU - Carvalho, Carlos PY - 1998/02/05/ UR - http://dx.doi.org/10.1056/NEJM199802053380602 ER -