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- Title
Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial.
- Authors
Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators; Cavalcanti, Alexandre Biasi; Suzumura, Érica Aranha; Laranjeira, Ligia Nasi; Paisani, Denise de Moraes; Damiani, Lucas Petri; Guimarães, Helio Penna; Romano, Edson Renato; Regenga, Marisa de Moraes; Taniguchi, Luzia Noriko Takahashi; Teixeira, Cassiano; Pinheiro de Oliveira, Roselaine; Machado, Flavia Ribeiro; Diaz-Quijano, Fredi Alexander; Filho, Meton Soares de Alencar; Maia, Israel Silva; Caser, Eliana Bernardete; Filho, Wilson de Oliveira; Borges, Marcos de Carvalho; Martins, Priscilla de Aquino
- Abstract
<bold>Importance: </bold>The effects of recruitment maneuvers and positive end-expiratory pressure (PEEP) titration on clinical outcomes in patients with acute respiratory distress syndrome (ARDS) remain uncertain.<bold>Objective: </bold>To determine if lung recruitment associated with PEEP titration according to the best respiratory-system compliance decreases 28-day mortality of patients with moderate to severe ARDS compared with a conventional low-PEEP strategy.<bold>Design, Setting, and Participants: </bold>Multicenter, randomized trial conducted at 120 intensive care units (ICUs) from 9 countries from November 17, 2011, through April 25, 2017, enrolling adults with moderate to severe ARDS.<bold>Interventions: </bold>An experimental strategy with a lung recruitment maneuver and PEEP titration according to the best respiratory-system compliance (n = 501; experimental group) or a control strategy of low PEEP (n = 509). All patients received volume-assist control mode until weaning.<bold>Main Outcomes and Measures: </bold>The primary outcome was all-cause mortality until 28 days. Secondary outcomes were length of ICU and hospital stay; ventilator-free days through day 28; pneumothorax requiring drainage within 7 days; barotrauma within 7 days; and ICU, in-hospital, and 6-month mortality.<bold>Results: </bold>A total of 1010 patients (37.5% female; mean [SD] age, 50.9 [17.4] years) were enrolled and followed up. At 28 days, 277 of 501 patients (55.3%) in the experimental group and 251 of 509 patients (49.3%) in the control group had died (hazard ratio [HR], 1.20; 95% CI, 1.01 to 1.42; P = .041). Compared with the control group, the experimental group strategy increased 6-month mortality (65.3% vs 59.9%; HR, 1.18; 95% CI, 1.01 to 1.38; P = .04), decreased the number of mean ventilator-free days (5.3 vs 6.4; difference, -1.1; 95% CI, -2.1 to -0.1; P = .03), increased the risk of pneumothorax requiring drainage (3.2% vs 1.2%; difference, 2.0%; 95% CI, 0.0% to 4.0%; P = .03), and the risk of barotrauma (5.6% vs 1.6%; difference, 4.0%; 95% CI, 1.5% to 6.5%; P = .001). There were no significant differences in the length of ICU stay, length of hospital stay, ICU mortality, and in-hospital mortality.<bold>Conclusions and Relevance: </bold>In patients with moderate to severe ARDS, a strategy with lung recruitment and titrated PEEP compared with low PEEP increased 28-day all-cause mortality. These findings do not support the routine use of lung recruitment maneuver and PEEP titration in these patients.<bold>Trial Registration: </bold>clinicaltrials.gov Identifier: NCT01374022.
- Subjects
LUNG volume measurements; POSITIVE end-expiratory pressure; ADULT respiratory distress syndrome; MORTALITY; HEALTH outcome assessment; VOLUMETRIC analysis; RANDOMIZED controlled trials; PATIENTS; ADULT respiratory distress syndrome treatment; COMPARATIVE studies; INTENSIVE care units; RESEARCH methodology; MEDICAL cooperation; PNEUMOTHORAX; RESEARCH; RESPIRATORY measurements; EVALUATION research; TREATMENT effectiveness
- Publication
JAMA: Journal of the American Medical Association, 2017, Vol 318, Issue 14, p1335
- ISSN
0098-7484
- Publication type
journal article
- DOI
10.1001/jama.2017.14171