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ARDSNet Lower Tidal Volume Ventilatory Strategy May Generate Intrinsic Positive End-Expiratory Pressure in Patients with Acute Respiratory Distress Syndrome

Dipartimento di Chirurgia-Terapia Intensiva, Cattedre di Anestesiologia e Rianimazione, Ospedale S. Chiara, Università di Pisa, Pisa, Italy; Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, Washington; and Department of Critical Care Medicine, St. Michael's Hospital, Interdepartmental Division of Critical Care Medicine, Respiratory Division, Department of Medicine, University of Toronto, Ontario, Canada

Correspondence and requests for reprints should be addressed to V. Marco Ranieri, Dipartimento di discipline Medico-Chirurgiche, Sezione di Anestesiologia e Rianimazione, Ospedale S. Giovanni Battista, Università di Torino, Corso Dogliotti 14, 10126 Torino, Italy. E-mail: mranieri{at}teseo.it

The ARDSNet trial revealed that the use of a smaller tidal volume (V_T) reduced mortality by 22%. However, three earlier studies that lowered V_T did not find a decrease in mortality. We tested the hypothesis that the increased respiratory rate used in the ARDSNet lower V_T strategy might have led to intrinsic positive end-expiratory pressure (PEEP_i), raising total PEEP (PEEP_total). Ten patients with acute respiratory distress syndrome (ARDS) were ventilated using the ARDSNet lower V_T protocol. Respiratory rate was then reduced (10–15 breaths/minute) to obtain a V_T of 12 ml/kg (ARDSNet traditional V_T). PEEP on the ventilator (PEEP_nominal: 10.1 ± 0.7 cm H₂O), FI_O2 (0.7 ± 0.1), and minute ventilation (V_E: 12.4 ± 1.7 L/minute) were set using the ARDSNet protocol and maintained constant during the two ventilatory strategies. Values of airway pressure at end-expiration of a regular breath (PEEP_external) and 3–5 seconds after the onset of an end-expiratory occlusion (PEEP_total) were measured. PEEP_i was calculated by subtracting PEEP_external from PEEP_total. PEEP_total and PEEP_i were, respectively, 16.3 ± 2.9 and 5.8 ± 3.0 cm H₂O during the lower V_T strategy and 11.7 ± 0.9 and 1.4 ± 1.0 cm H₂O during the traditional V_T strategy (p < 0.01). The reduced mortality observed with the ARDSNet strategy may have been due to the protective effect of a higher PEEP_total.

Key Words: ARDS • protective ventilatory strategy • PEEP • intrinsic PEEP

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