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Published ahead of print on August 4, 2005, doi:10.1164/rccm.200501-048CP

Am. J. Respir. Crit. Care Med., Volume 172, Number 10, November 2005, 1241-1245

A more recent version of this article appeared on November 15, 2005
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Submitted on January 11, 2005
Accepted on August 4, 2005

Tidal Volume Reduction In Patients With Acute Lung Injury When Plateau Pressures Are Not High

David N Hager1*, Jerry A Krishnan1, Douglas L Hayden2, and Roy G Brower1

1 Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA, 2 Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA

* To whom correspondence should be addressed. E-mail: dhager1{at}jhmi.edu.

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. In this Critical Care Perspective we address the question "Is there a safe upper limit to inspiratory plateau pressure in ALI/ARDS patients?". We reviewed data from animal models with and without pre-existing 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 does not support the commonly held view that inspiratory plateau pressures of 30-35 cm H2O are safe. We could not identify an upper limit for safe plateau pressures in ALI/ARDS patients.
Key words: ALI, ARDS, Plateau Pressure, Mechanical Ventilation




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