Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome Academic Article uri icon

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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.

authors

  • Cavalcanti, Alexandre Biasi
  • Suzumura, Érica Aranha
  • Laranjeira, Ligia Nasi
  • Paisani, Denise de Moraes
  • Damiani, Lucas Petri
  • Guimarães, Helio Penna
  • Romano, Edson Renato
  • Regenga, Marisa de Moraes
  • Taniguchi, Luzia Noriko Takahashi
  • Teixeira, Cassiano
  • Pinheiro de Oliveira, Roselaine
  • Machado, Flavia Ribeiro
  • Diaz-Quijano, Fredi Alexander
  • Filho, Meton Soares de Alencar
  • Maia, Israel Silva
  • Caser, Eliana Bernardete
  • Filho, Wilson de Oliveira
  • Borges, Marcos de Carvalho
  • Martins, Priscilla de Aquino
  • Matsui, Mirna
  • Ospina-Tascón, Gustavo Adolfo
  • Giancursi, Thiago Simões
  • Giraldo-Ramirez, Nelson Dario
  • Vieira, Silvia Regina Rios
  • Assef, Maria da Graça Pasquotto de Lima
  • Hasan, Mohd Shahnaz
  • Szczeklik, Wojciech
  • Rios, Fernando
  • Amato, Marcelo Britto Passos
  • Berwanger, Otávio
  • Ribeiro de Carvalho, Carlos Roberto

publication date

  • October 10, 2017