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Published ahead of print on August 4, 2005, doi:10.1164/rccm.200501-048CP
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American Journal of Respiratory and Critical Care Medicine Vol 172. pp. 1241-1245, (2005)
© 2005 American Thoracic Society
doi: 10.1164/rccm.200501-048CP

Critical Care Perspective

Tidal Volume Reduction in Patients with Acute Lung Injury When Plateau Pressures Are Not High

David N. Hager, Jerry A. Krishnan, Douglas L. Hayden, Roy G. Brower for the ARDS Clinical Trials Network

Department of Medicine, Johns Hopkins University, Baltimore, Maryland; and Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts

Correspondence and requests for reprints should be addressed to David N. Hager, M.D., 1830 East Monument Street, Room 549, Baltimore, MD 21205. E-mail: dhager1{at}jhmi.edu

ABSTRACT

Use of a volume- and pressure-limited mechanical ventilation strategy improves clinical outcomes of patients with acute lung injury and acute respiratory distress syndrome (ALI/ARDS). However, the extent to which tidal volumes and inspiratory airway pressures should be reduced to optimize clinical outcomes is a controversial topic. This article addresses the question, "Is there a safe upper limit to inspiratory plateau pressure in patients with ALI/ARDS?" We reviewed data from animal models with and without preexisting lung injury, studies of normal human respiratory system mechanics, and the results of five clinical trials of lung-protective mechanical ventilation strategies. We also present an original analysis of data from the largest of the five clinical trials. The available data from each of these assessments do not support the commonly held view that inspiratory plateau pressures of 30 to 35 cm H2O are safe. We could not identify a safe upper limit for plateau pressures in patients with ALI/ARDS.

Key Words: acute respiratory distress syndrome • acute lung injury • plateau • mechanical ventilation




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