title: Low stretch ventilation strategy in acute respiratory distress syndrome: eight years of clinical experience in a single center.
abstract: BACKGROUND
  In recent years, protective ventilation with airway pressure limitation has constituted a major advance in acute respiratory distress syndrome treatment and has led to a substantial improvement in prognosis. With this therapeutic rationale, one may even question nowadays whether the severity of respiratory failure still influences mortality.
  
  
  OBJECTIVE
  To determine whether the severity of respiratory failure, scored according to the usual criteria, still influences mortality in acute respiratory distress syndrome patients when a low stretch ventilation was used and to assess the impact on mortality of other nonpulmonary organ dysfunction, particularly circulatory failure.
  
  
  METHODS
  A retrospective study conducted in the medical intensive care unit of a French university hospital from October 1993 to December 2001. PATIENTS A total of 150 acute respiratory distress syndrome patients who were administered uniform protective ventilation with a limited plateau pressure (<30 cm H2O), a low positive end-expiratory pressure (<10 cm H2O), and the same strategy concerning hemodynamic support and dialysis when required.
  
  
  METHODS
  Mean age, general severity index (Simplified Acute Physiologic Score II), number of associated organ failures (Logistic Organ Dysfunction Score), respiratory severity indices (Pao2/Fio2, Lung Injury Severity Score), and severity of initial circulatory failure (circulatory failure present at admission or that developed during the first 48 hrs) were compared, according to recovery or death, and evaluated by a logistic regression model, which allows simultaneous control of multiple factors.
  
  
  RESULTS
  The average mortality rate for the whole group was 38%, with 93 patients recovering after an average duration of mechanical ventilation of 18 +/- 13 days. The major factor significantly and independently associated with probability of dying was the severity of circulatory failure (p =.0001, odds ratio = 10.17). Patients free from initial circulatory failure (39 patients) had a 95% recovery rate.
  
  
  CONCLUSIONS
  With our low stretch strategy, the severity of circulatory failure was the main determinant of acute respiratory distress syndrome prognosis. Patients with isolated respiratory failure during the first 48 hrs of respiratory support have an excellent chance of recovery when treated with protective ventilation associated with a low positive end-expiratory pressure.
authors.affiliation: Medical Intensive Care Unit, University Hospital Ambroise Paré, Assistance Publique Hôpitaux de Paris, Boulogne Cedex, France.
authors.forename: Bernard
authors.initials: B
authors.lastname: Page
authors.forename: Antoine
authors.initials: A
authors.lastname: Vieillard-Baron
authors.forename: Alain
authors.initials: A
authors.lastname: Beauchet
authors.forename: Philippe
authors.initials: P
authors.lastname: Aegerter
authors.forename: Sebastien
authors.initials: S
authors.lastname: Prin
authors.forename: François
authors.initials: F
authors.lastname: Jardin
mesh_terms: D018806:APACHE; D000368:Aged; D005260:Female; D005602:France / Q000453:epidemiology; D006439:Hemodynamics; D017052:Hospital Mortality; D006785:Hospitals, University; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000209:etiology; D016017:Odds Ratio; D011175:Positive-Pressure Respiration / Q000379:methods*; D011237:Predictive Value of Tests; D011379:Prognosis; D012128:Respiratory Distress Syndrome / Q000145:classification / Q000150:complications / Q000401:mortality* / Q000628:therapy*; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D016019:Survival Analysis; D013990:Tidal Volume; D013997:Time Factors; D016896:Treatment Outcome