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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.

Collaborators (472)

Tucci MR, Souza dos Santos L, França de Oliveira MC, Peres I, Freitas I, Reis H, Veríssimo A, Torres D, Barroso A, Semboloni Bitencourt W, Franco MR, Oliveira Lage J, Aparecida Pessoa Conde K, Charro FA, Naia A, de Brito Sobrinho E, Lameira Veríssimo A, Barros de Oliveira ME, Zampieri F, Ladeira JP, Cordioli R, Diogo Sala A, Tadahiro Ikeoka D, Baptista Filho MLA, Ray A, Guerra de Almeida A, Nazareno Conceição C, Ribeiro Salgado D, Rosso Verdeal JC, Martins GA, Semboloni Bitencourt W, Junqueira Ribeiro L, Vilela Siqueira H, Flávio Costa Filho F, Adler Maccagnan Pinheiro Besen B, Vieira do Nascimento Martins E, Aparecida Pereira J, Milioli Ferreira D, Alves Ferreira Gonçalves F, de Souza Nobrega M, Barros Duarte IJ, Nobre V, Miranda Barreto Mourão L, Gómez Ravetti C, Scalzo AC, Martins De Stefano L, Gut AL, Nogueira Filho W, Gatti Cirillo C, Ishiwaki Jr S, Lobo S, Elias de Oliveira N, Fernandes Machado L, Sisconetto L, Rios Vieira SR, Fialkow L, Fontoura Prado K, Franke C, Barberena Moraes R, Christmann Wawrzeniak I, Rech TH, Parolo E, Almeida Victorino J, Marques Barroso C, Marçal de Vasconcelos MO, Souza da Silva R, Lesti Esteves AR, Camassola AP, Antoniazzi R, Griebler M, Favretto J, Romano M, Franz da Costa A, Werneck V, Miura MC, Farran J, de Vasconcelos R, Isola A, Resende E, Goulart R, Luzzi S, Réa-Neto A, de Oliveira MC, Bruinje Cosentino MF, Martins Dzivielevski B, Reese FB, Ferreira da Silva SD, Elias Aquim E, Girotto F, Helenditi Fernandes Camurça Martins R, Lima de Andrade A, de Oliveira Filho W, Breckenfeld Heirel DC, Ryoji Takatani R, Dias de Almeida S, Medina Matos A, Iwamoto T, do Val Tavares PE, Valiatti JL, de Lucca FC, Fornazari JC, Dias Brugugnolli I, de Araújo Nazaré M, Nascimento Loureiro N, Vasconcelos de Sousa G, Staffa Gonzaga da Silva L, de Aquino Martins P, dos Anjos Sad FC, Stucchi EM, Melo Silva R, Fonseca Silva T, Mendes Filho SP, Borba Pereira T, da Silva PN, Martines Moralez G, Abrantes Saraiva S, Abrunhosa A, Ranger C. Chagas CE, Thompson MM, Pinto Gonçalves CH, de Oliveira Dias R, Schwan Filho F, Magalhães Carvalho Grion C, Mezzaroba AL, Festti J, de Aquino Martins P, Massariol TC, de Souza Jr GF, Martins Lima Silva M, de Souza Andrade Neto J, Costa G, Souza Ribeiro II M, Coelho M, Cruz Carbonell RC, de Souza Trindade R, Valente Barbas CS, Domingos Correa T, Serpa Neto A, Santucci Cesar de Assunção M, Vilela Costa Pinto B, Gonçalves Libânio P, Réa-Neto A, da Silva Motta Jr J, Elias Aquim E, Santa Maria Lucin G, Macedo Araujo L, de Alencar Filho MS, Anibal Leite Barros Agostinho T, de Andrade KM, da Silva MS, Pereira da Silva E, Mousinho Gomes RL, Campos NMP, Fonseca de Sousa J, Ramos Nicolau da Costa L, de Carvalho Fonseca Assunção NS, Martins de Lima G, Teixeira C, Pinheiro de Oliveira R, Gasparetto Maccari J, de Campos Balzano P, Tagliari L, Metran Nascente AP, de Carvalho MA, Buttignol M, Henn Moura R, Vinicius Pereira M, Alberti da Silva G, Akemi Higo M, Morales M, Andrade AHV, de Paiva AP, da Silva KS, Andrioli de Araujo P, Cordeiro de Abreu Filho CA, Abdalla G, Loureiro Sebold M, Moreira R, Caldeira Filho M, de Brito Cordeiro R, Pfuetzenreiter F, Costa Carvalho LF, da Silva Guimarães BL, de Faria Cordeiro H, Pimentel Alvim SH, do Espirito Santo JA, Silva Maia I, Pincelli M, Zandonai CL, Burigo Grumann AC, Kretzer LP, Nedel W, Manozzo Boniatti M, Santos Pellegrini JA, da Silva Marques L, Girardelli Baptista WC, da Silva Franco RS, Moreira de Sousa M, de Marchi Benfica AF, Veiga de Oliveira AL, Reis DL, Morais MO, Santa Rosa Santana H, Murilo Domingues Jr S, de Menezes Ferreira C, Amado Rabelo L, Menezes de Rezende C, Riccio P, Silva de Almeida P, Rubini P, da Graça Pasquotto de Lima Assef M, Nardela R, Locks Stahlhöfer L, Gatelli Noronha C, de Azevedo Naves S, Dias da Silva F, Mazza BF, Longhi Simões de Almeida S, Mayumi Higa R, Papacídero CH, Lima Silva MM, de Assunção Melo L, Miranda Mafra Oliveira M, Matos Brito Coelho C, Machado JA, de Souza Machado YL, Vitor Fera J, dos Santos Ramos NC, Botelho Foernges R, de Souza RR, Rutzen W, Villasante Troncoso EM, Paiva TKB, Vieira de Lacerda NM, Aires de Araújo Neto J, de Oliveira Maia M, Bastos de Moura E, Brocco Magnan G, Soares Nasrala ML, Campos Tonussi RL, Kohl Pinheiro E, Simões da Silva F, Dal-Pizzol F, Schmitz de Figueiredo F, Ritter C, de Vasconcellos Baldisserotto S, Blattner C, Saldanha dos Santos R, da Silva Bettega F, de Azevedo Naves S, Dias da Silva F, Almeida Delfino Duarte P, Tozo TC, Peliser P, Deczka Morsch R, Guimarães Leal Guadalupe E, Souza Amorim D, Rezegue de Moraes Rego L, Azevedo L, Ramos F, Pastore L, Nery P, Spegiorin Moreno M, Nakad Orsatti V, Yudi Horikawa F, Samartino Zavanelli G, Adrieno Westphal G, Sperotto G, Dadam M, Nunes M, Pantaleão SL, Camargo Narciso R, Bernadete Caser E, Falcão JG, Genelhu G, Lessa Soares F, Silva Sales B, Rebello de Jesus K, Correia Santos Bonomo D, Martins Arruda J, de Pinho JC, Belacho Azeredo Coutinho J, Braga Hagreaves Ribeiro de Freitas R, de Souza Oliveira Garcia T, Frizera Vassallo P, Buarque Souza de Lima MH, Matsui M, Eberhart Neto E, Satoshi Inagaki A, Oliveira de Paula AE, Amador Correia T, Nomoto S, Seiji Ueno Gil F, Florizel Almeida de Araújo M, Bezerra Lima Z, Simões Giancursi T, Rejane de Lima C, Costa M, Osaku EF, Jorge AC, Rodrigues da Cruz M, da Cunha S, Silva Cavallaro Torres K, Rocha Rodrigues da Silva F, Lisboa de Souza R, Osni Machado F, Buss EK, Cattelan Bonorino K, Germano A, Bin da Silva SR, Herek A, Tavares Gurgel SJ, Magalhães Carvalho Grion C, Sanches Laranjeira A, Toshiyuki Tanita M, Tibery Queiroz Cardoso L, Osorio Guerreiro M, Peres Bainy M, de Oliveira Teixeira L, Colozza Mecatti G, Carolina Salomão M, Ribeiro Moreira A, Vantini Capasso Palamim C, Réa-Neto A, Elias Aquim E, Deucher RAO, Castro Escobar Furlan F, Rodrigues Torres de Carvalho F, Muniz Jr R, Penna Guimarães H, Conceição Andrade L, Abrahão Hajjar L, Barbosa Gomes Galas FR, Pinheiro de Almeida J, Marco R, Peixoto E, Hirata F, Yen Ju C, Bonaccorsi Fernandino B, Lage de Assis Rocha D, Azzi Barbosa N, Dias Alves J, Furtado Lamego L, de Linhares JM, Ferreira Sousa M, Ferreira de Souza MM, Guimarães de Carvalho FL, Aparecida Leite M, Torres P, Bolognese D, Lacerda V, Cisari G, Souza Marques A, Amarante Costa A, Bonin Campos L, de Carvalho Borges M, Lovato WJ, Guimarães Dantas B, Ribeiro Campos D, Pires Barrientto LC, Rossi Peras Américo V, Barboza Carnevalli Bueno T, Morales D, Mara Gomes T, Barbosa Cerantola R, Pinheiro de Oliveira R, Teixeira C, Höher J, Sá Malbouisson LM, Matheus Cadamuro F, Bassi E, Maia R, Dias e Santos JA, Oliveira C, Balzi AP, Tierno P, Marques Andrade G, Delascio Lopes R, Ramos Mello M, Penna Guimarães H, Vendrame LS, Ribeiro Machado F, Baccaro Rossetti Santana H, de Carvalho Jr A, Marques Ferreira Mendez V, de Araujo Macedo Pinto W, dos Santos Francisco R, Steponovicius Piedade Cruz F, Silva de Araujo A, Paiva de Souza A, Teixeira Pinheiro T, Martins Santos T, Gontijo-Coutinho CM, Franci D, de Carvalho-Filho MA, Ribas Rosa de Oliveira AM, Silva Jr JM, Costa Lisboa T, Peretti Torelly A, Silva de Souza A, Hadrich M, Schwarz P, Berto P, Santos Pellegrini JA, Teixeira de Gois AF, Silva Jr M, Gessolo Lins P, Cavalcante Lola Biazzoto EP, Dragosavac D, Ribeiro de Carvalho CR, Passos Amato MB, Toufen Jr C, Ribeiro de Santis Santiago R, Hirota AS, Rodrigues Jr M, Dias Chiavegato L, Bastos Vieira PC, Marson M. F. de Almeida M, Barbosa PG, Pereira Santos JR, Nogueira de Paula L, Piras C, Giuberti Jr J, Siqueira da Silva A, Conti Ramos R, Diaz-Quijano FA, Plata Valdivieso R, Gonzalez HH, Ortiz M, Ospina-Tascón GA, Bautista-Rincón DF, Quiñones E, Calderon LE, Vargas M, Pizarro C, Orozco Levi M, Espitia Hernández AM, Cadavid Gutierrez C, Giraldo Ramirez N, Gallego DA, Naranjo Sierra S, Ortiz G, Esneda Rocha Gaona M, Garay M, Vieda E, Bermúdez WF, Castañeda JA, Cortegiani A, Russotto V, Raineri SM, Giarratano A, Shahnaz Hasan M, Rai Hakumat Rai V, Fadhil Hadi bin Jamaluddin M, Afiq Syahmi Ramli M, Szczeklik W, Gorka J, Nowak I, Seczynska b, Sega a, Paulino C, Póvoa P, Belda FJ, Ferrando C, Carbonell JA, Puig J, Soro M, Nin N, Hurtado J, Gacel A, Gaudin A, Sande L.

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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