• Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators, Alexandre Biasi Cavalcanti, Érica Aranha Suzumura, Ligia Nasi Laranjeira, PaisaniDenise de MoraesDMHCor Research Institute, São Paulo, Brazil., Lucas Petri Damiani, Helio Penna Guimarães, Edson Renato Romano, Marisa de Moraes Regenga, Luzia Noriko Takahashi Taniguchi, Cassiano Teixeira, Pinheiro de OliveiraRoselaineRIrmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil., Flavia Ribeiro Machado, Fredi Alexander Diaz-Quijano, Meton Soares de Alencar Filho, Israel Silva Maia, Eliana Bernardete Caser, Wilson de Oliveira Filho, BorgesMarcos de CarvalhoMCUnidade de Emergência do Hospital das Clínicas da FMRP-USP, Ribeirão Preto, Brazil., Priscilla de Aquino Martins, Mirna Matsui, Gustavo Adolfo Ospina-Tascón, Thiago Simões Giancursi, Nelson Dario Giraldo-Ramirez, VieiraSilvia Regina RiosSRRHospital de Clínicas de Porto Alegre, Porto Alegre, Brazil., Maria da Graça Pasquotto de Lima Assef, Mohd Shahnaz Hasan, Wojciech Szczeklik, Fernando Rios, AmatoMarcelo Britto PassosMBPCardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), University of São Paulo, São Paulo, Brazil., Otávio Berwanger, and Ribeiro de CarvalhoCarlos RobertoCRCardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), University of São Paulo, São Paulo, Brazil..
• HCor Research Institute, São Paulo, Brazil.
• JAMA. 2017 Oct 10; 318 (14): 1335-1345.

ImportanceThe effects of recruitment maneuvers and positive end-expiratory pressure (PEEP) titration on clinical outcomes in patients with acute respiratory distress syndrome (ARDS) remain uncertain.ObjectiveTo 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.Design, Setting, And ParticipantsMulticenter, 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.InterventionsAn 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.Main Outcomes And MeasuresThe 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.ResultsA 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.Conclusions And RelevanceIn 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.Trial Registrationclinicaltrials.gov Identifier: NCT01374022.

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