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Am. J. Respir. Crit. Care Med., Volume 158, Number 6, December 1998, 1831-1838

Tidal Volume Reduction for Prevention of Ventilator-induced Lung Injury in Acute Respiratory Distress Syndrome

LAURENT BROCHARD, FRANÇOISE ROUDOT-THORAVAL, ERIC ROUPIE, CHRISTOPHE DELCLAUX, JEAN CHASTRE, ENRIQUE FERNANDEZ-MONDÉJAR, EVA CLÉMENTI, JORDI MANCEBO, PHILLIP FACTOR, DIMITRI MATAMIS, MARCO RANIERI, LLUIS BLANCH, GIUSEPPE RODI, HERVÉ MENTEC, DIDIER DREYFUSS, MIGUEL FERRER, CHRISTIAN BRUN-BUISSON, MARTIN TOBIN, FRANÇOIS LEMAIRE, and The Multicenter Trial Group on Tidal Volume Reduction in ARDS

Medical Intensive Care Unit, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris XII and INSERM U 492, Créteil, France

Because animal studies have demonstrated that mechanical ventilation at high volume and pressure can be deleterious to the lungs, limitation of airway pressure, allowing hypercapnia if necessary, is already used for ventilation of acute respiratory distress syndrome (ARDS). Whether a systematic and more drastic reduction is necessary is debatable. A multicenter randomized study was undertaken to compare a strategy aimed at limiting the end-inspiratory plateau pressure to 25 cm H2O, using tidal volume (VT) below 10 ml/kg of body weight, versus a more conventional ventilatory approach (with regard to current practice) using VT at 10 ml/kg or above and close to normal PaCO2. Both arms used a similar level of positive end-expiratory pressure. A total of 116 patients with ARDS and no organ failure other than the lung were enrolled over 32 mo in 25 centers. The two groups were similar at inclusion. Patients in the two arms were ventilated with different VT (7.1 ± 1.3 versus 10.3 ± 1.7 ml/kg at Day 1, p < 0.001) and plateau pressures (25.7 ± 5.0 versus 31.7 ± 6.6 cm H2O at Day 1, p < 0.001), resulting in different PaCO2 (59.5 ± 15.0 versus 41.3 ± 7.6 mm Hg, p < 0.001) and pH (7.28 ± 0.09 versus 7.4 ± 0.09, p < 0.001), but a similar level of oxygenation. The new approach did not reduce mortality at Day 60 (46.6% versus 37.9% in control subjects, p = 0.38), the duration of mechanical ventilation (23.1 ± 20.2 versus 21.4 ± 16.3 d, p = 0.85), the incidence of pneumothorax (14% versus 12%, p = 0.78), or the secondary occurrence of multiple organ failure (41% versus 41%, p = 1). We conclude that no benefit could be observed with reduced VT titrated to reach plateau pressures around 25 cm H2O compared with a more conventional approach in which normocapnia was achieved with plateau pressures already below 35 cm H2O.




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Ann. Thorac. Surg., January 1, 2001; 71(1): 394 - 396.
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J DAKIN and T W EVANS
Progress in ARDS research: a protection racket?
Thorax, January 1, 2001; 56(1): 2 - 3.
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 Am. J. Respir. Crit. Care Med.Home page
R. P. MARSHALL, G. BELLINGAN, S. WEBB, A. PUDDICOMBE, N. GOLDSACK, R. J. MCANULTY, and G. J. LAURENT
Fibroproliferation Occurs Early in the Acute Respiratory Distress Syndrome and Impacts on Outcome
Am. J. Respir. Crit. Care Med., November 1, 2000; 162(5): 1783 - 1788.
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J. G. Laffey, B. P. Kavanagh, L. Ney, W. M. Kuebler, Y. Oba, G. A. Salzman, R. G. Brower, M. A. Matthay, and A. Wheeler
Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury
N. Engl. J. Med., September 14, 2000; 343(11): 812 - 814.
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J. A. Krishnan and R. G. Brower
High-Frequency Ventilation for Acute Lung Injury and ARDS
Chest, September 1, 2000; 118(3): 795 - 807.
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A. Esteban, I. Alia, F. Gordo, R. de Pablo, J. Suarez, G. Gonzalez, and J. Blanco
Prospective Randomized Trial Comparing Pressure-Controlled Ventilation and Volume-Controlled Ventilation in ARDS
Chest, June 1, 2000; 117(6): 1690 - 1696.
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The Acute Respiratory Distress Syndrome Network
Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome
N. Engl. J. Med., May 4, 2000; 342(18): 1301 - 1308.
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L. B. Ware and M. A. Matthay
The Acute Respiratory Distress Syndrome
N. Engl. J. Med., May 4, 2000; 342(18): 1334 - 1349.
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M. J. Tobin
Culmination of an Era in Research on the Acute Respiratory Distress Syndrome
N. Engl. J. Med., May 4, 2000; 342(18): 1360 - 1361.
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 Am. J. Respir. Crit. Care Med.Home page
A. ESTEBAN, A. ANZUETO, I. ALÍA, F. GORDO, C. APEZTEGUÍA, F. PÁLIZAS, D. CIDE, R. GOLDWASER, L. SOTO, G. BUGEDO, et al.
How Is Mechanical Ventilation Employed in the Intensive Care Unit? . An International Utilization Review
Am. J. Respir. Crit. Care Med., May 1, 2000; 161(5): 1450 - 1458.
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S. F. van Eeden, M. Emilia Klut, M. A. Leal, J. Alexander, Z. Zonis, and P. Skippen
Partial Liquid Ventilation with Perfluorocarbon in Acute Lung Injury . Light and Transmission Electron Microscopy Studies
Am. J. Respir. Cell Mol. Biol., April 1, 2000; 22(4): 441 - 450.
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N. Petrucci, V. M. Ranieri, P. M. Suter, and A. S. Slutsky
Ventilator-Induced Lung Injury
JAMA, February 23, 2000; 283(8): 1003 - 1004.
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A. Vieillard-Baron, Y. Loubieres, J.-M. Schmitt, B. Page, O. Dubourg, and F. Jardin
Cyclic changes in right ventricular output impedance during mechanical ventilation
J Appl Physiol, November 1, 1999; 87(5): 1644 - 1650.
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A. Jubran
Advances in Respiratory Monitoring During Mechanical Ventilation
Chest, November 1, 1999; 116(5): 1416 - 1425.
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V. M. Ranieri, P. M. Suter, C. Tortorella, R. De Tullio, J. M. Dayer, A. Brienza, F. Bruno, and A. S. Slutsky
Effect of Mechanical Ventilation on Inflammatory Mediators in Patients With Acute Respiratory Distress Syndrome: A Randomized Controlled Trial
JAMA, July 7, 1999; 282(1): 54 - 61.
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L. D. Hudson
Progress in Understanding Ventilator-Induced Lung Injury
JAMA, July 7, 1999; 282(1): 77 - 78.
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M. A. Matthay
Conference Summary: Acute Lung Injury
Chest, July 1, 1999; 116(2007): 119S - 126S.
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D. DREYFUSS, L. MARTIN-LEFÈVRE, and G. SAUMON
Hyperinflation-Induced Lung Injury during Alveolar Flooding in Rats . Effect of Perfluorocarbon Instillation
Am. J. Respir. Crit. Care Med., June 1, 1999; 159(6): 1752 - 1757.
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