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Original Article Effect of a Protective-Ventilation Strategy on Mortality in the Acute Respiratory Distress Syndrome Marcelo Britto Passos Amato, M.D., Carmen Silvia Valente Barbas, M.D., Denise Machado Medeiros, M.D., Ricardo Borges Magaldi, M.D., Guilherme Paula Schettino, M.D., Geraldo Lorenzi-Filho, M.D., Ronaldo Adib Kairalla, M.D., Daniel Deheinzelin, M.D., Carlos Munoz, M.D. Installing Cdr In Free Pbx Install. , Roselaine Oliveira, M.D., Teresa Yae Takagaki, M.D., and Carlos Roberto Ribeiro Carvalho, M.D. N Engl J Med 1998; 338:347-354 DOI: 10.1056/NEJM80602. 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. Mechanical ventilation can damage the lungs.

Lesions at the alveolar–capillary interface, alterations in permeability, and edema have repeatedly been shown to occur in animals subjected to adverse patterns of mechanical ventilation. In clinical practice, however, the “mechanical stretch” caused by conventional ventilation has been found to be detrimental in only a few uncontrolled studies. Large variations in the susceptibility of individual animal species and the apparent success of mechanical ventilation based on a strategy of using the lowest positive end-expiratory pressure (PEEP) that results in acceptable oxygenation suggest that the devastating effects observed in animals cannot be easily extrapolated to humans. We recently demonstrated that mechanical lung protection can be provided in patients with the acute respiratory distress syndrome, resulting in better pulmonary function and higher rates of weaning from the ventilator. Briefly, lung protection was based on a strategy of maintaining low inspiratory driving pressures (. Stabilizing Procedures and Randomization After enrollment, all patients underwent a standardized regimen of ventilatory–hemodynamic procedures for at least 30 minutes (control period), during which time their initial clinical condition was evaluated and stabilized. General Ventilatory Support Protective or conventional mechanical ventilation was rigorously maintained until the patient was extubated or died.

Each patient was connected to a closed system for aspirating tracheal secretions; the patient remained connected to the ventilator during aspiration, minimizing temporary drops in airway pressure. In both groups, the target partial pressure of arterial oxygen was 80 mm Hg, and the PEEP level was never set below 5 cm of water, even during weaning from the ventilator. The weaning procedure was the same in the two groups: a gradual decrease in the level of pressure support. Patients received ventilation exclusively through endotracheal tubes. Conventional Approach We sought to maintain an arterial carbon dioxide level of 35 to 38 mm Hg, independent of airway pressures, and an inspiratory oxygen fraction of less than 0.6 with adequate systemic oxygen delivery.