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JAMA. 2017 Oct 10;318(14):1335-1345. doi: 10.1001/jama.2017.14171.

Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial.

Author information

1
HCor Research Institute, São Paulo, Brazil.
2
Hospital Moinhos de Vento, Porto Alegre, Brazil.
3
Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil.
4
Anesthesiology, Pain, and Intensive Care Department, Federal University of São Paulo-UNIFESP, São Paulo, Brazil.
5
Epidemiology Department, School of Public Health, University of São Paulo, São Paulo, Brazil.
6
Hospital Maternidade São Vicente de Paulo, Barbalha, Brazil.
7
Hospital Nereu Ramos, Florianópolis, Brazil.
8
Hospital Unimed Vitória, Vitória, Brazil.
9
Hospital e Pronto-Socorro 28 de Agosto, Manaus, Brazil.
10
Unidade de Emergência do Hospital das Clínicas da FMRP-USP, Ribeirão Preto, Brazil.
11
Hospital Estadual Dr Jayme dos Santos Neves, Serra, Brazil.
12
Hospital Universitário da Universidade Federal da Grande Dourados, Dourados, Brazil.
13
Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Cali, Colombia.
14
Hospital Universitário do Oeste do Paraná, Cascavel, Brazil.
15
Hospital Pablo Tóbon Uribe, Medellín, Colombia.
16
Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.
17
Hospital Regional Hans Dieter Schmidt, Joinville, Brazil.
18
University Malaya Medical Centre, Kuala Lumpur, Malaysia.
19
Jagiellonian University Medical College; Department of Intensive Care and Perioperative Medicine, Krakow, Poland.
20
Hospital Nacional Alejandro Posadas, Moron, Argentina.
21
Cardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), University of São Paulo, São Paulo, Brazil.

Abstract

Importance:

The effects of recruitment maneuvers and positive end-expiratory pressure (PEEP) titration on clinical outcomes in patients with acute respiratory distress syndrome (ARDS) remain uncertain.

Objective:

To 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 Participants:

Multicenter, 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.

Interventions:

An 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 Measures:

The 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.

Results:

A 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 Relevance:

In 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 Registration:

clinicaltrials.gov Identifier: NCT01374022.

PMID:
28973363
PMCID:
PMC5710484
DOI:
10.1001/jama.2017.14171
[Indexed for MEDLINE]
Free PMC Article

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