Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial.
BACKGROUND
The need for lung protection is universally accepted, but the optimal level of positive end-expiratory pressure (PEEP) in patients with acute lung injury (ALI) or acute respiratory distress syndrome remains debated.


OBJECTIVE
To compare the effect on outcome of a strategy for setting PEEP aimed at increasing alveolar recruitment while limiting hyperinflation to one aimed at minimizing alveolar distension in patients with ALI.


METHODS
A multicenter randomized controlled trial of 767 adults (mean [SD] age, 59.9 [15.4] years) with ALI conducted in 37 intensive care units in France from September 2002 to December 2005.


METHODS
Tidal volume was set at 6 mL/kg of predicted body weight in both strategies. Patients were randomly assigned to a moderate PEEP strategy (5-9 cm H(2)O) (minimal distension strategy; n = 382) or to a level of PEEP set to reach a plateau pressure of 28 to 30 cm H(2)O (increased recruitment strategy; n = 385).


METHODS
The primary end point was mortality at 28 days. Secondary end points were hospital mortality at 60 days, ventilator-free days, and organ failure-free days at 28 days.


RESULTS
The 28-day mortality rate in the minimal distension group was 31.2% (n = 119) vs 27.8% (n = 107) in the increased recruitment group (relative risk, 1.12 [95% confidence interval, 0.90-1.40]; P = .31). The hospital mortality rate in the minimal distension group was 39.0% (n = 149) vs 35.4% (n = 136) in the increased recruitment group (relative risk, 1.10 [95% confidence interval, 0.92-1.32]; P = .30). The increased recruitment group compared with the minimal distension group had a higher median number of ventilator-free days (7 [interquartile range {IQR}, 0-19] vs 3 [IQR, 0-17]; P = .04) and organ failure-free days (6 [IQR, 0-18] vs 2 [IQR, 0-16]; P = .04). This strategy also was associated with higher compliance values, better oxygenation, less use of adjunctive therapies, and larger fluid requirements.


CONCLUSIONS
A strategy for setting PEEP aimed at increasing alveolar recruitment while limiting hyperinflation did not significantly reduce mortality. However, it did improve lung function and reduced the duration of mechanical ventilation and the duration of organ failure.


BACKGROUND
clinicaltrials.gov Identifier: NCT00188058.
Mercat
Alain
A
Département de Réanimation Médicale et Médecine Hyperbare, CHU d'Angers, Angers, France. almercat@chu-angers.fr
Richard
Jean-Christophe M
JC
Vielle
Bruno
B
Jaber
Samir
S
Osman
David
D
Diehl
Jean-Luc
JL
Lefrant
Jean-Yves
JY
Prat
Gwenaël
G
Richecoeur
Jack
J
Nieszkowska
Ania
A
Gervais
Claude
C
Baudot
Jérôme
J
Bouadma
Lila
L
Brochard
Laurent
L
D000368:Aged; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D011175:Positive-Pressure Respiration; D012128:Respiratory Distress Syndrome / Q000503:physiopathology / Q000628:therapy*; D016019:Survival Analysis; D013990:Tidal Volume; D015300:Ventilator Weaning