title: Efficacy of positive end-expiratory pressure titration after the alveolar recruitment manoeuvre in patients with acute respiratory distress syndrome.
abstract: BACKGROUND
  In acute respiratory distress syndrome (ARDS), adequate positive end-expiratory pressure (PEEP) may decrease ventilator-induced lung injury by minimising overinflation and cyclic recruitment-derecruitment of the lung. We evaluated whether setting the PEEP using decremental PEEP titration after an alveolar recruitment manoeuvre (ARM) affects the clinical outcome in patients with ARDS.
  
  
  METHODS
  Fifty-seven patients with early ARDS were randomly assigned to a group given decremental PEEP titration following ARM or a table-based PEEP (control) group. PEEP and inspired fraction of oxygen (FiO2) in the control group were set according to the table-based combinations of FiO2 and PEEP of the ARDS network, by which we aimed to achieve a PEEP level compatible with an oxygenation target. In the decremental PEEP titration group, the oxygen saturation and static compliance were monitored as the patients performed the ARM along with the extended sigh method, which is designed to gradually apply and withdraw a high distending pressure over a prolonged period, and the decremental titration of PEEP.
  
  
  RESULTS
  The baseline characteristics did not differ significantly between the control and decremental PEEP titration groups. Initial oxygenation improved more in the decremental PEEP titration group than in the control group. However, dynamic compliance, tidal volume and PEEP were similar in the two groups during the first week. The duration of use of paralysing or sedative agents, mechanical ventilation, stay in the intensive care unit and mortality at 28 days did not differ significantly between the decremental PEEP titration and control groups.
  
  
  CONCLUSIONS
  The daily decremental PEEP titration after ARM showed only initial oxygenation improvement compared with the table-based PEEP method. Respiratory mechanics and patient outcomes did not differ between the decremental PEEP titration and control groups.
  
  
  BACKGROUND
  ClinicalTrials.gov identifier: ISRCTN79027921.
authors.affiliation: Department of Pulmonary and Critical Care Medicine, Inje University Ilsan Paik Hospital, Goyang-si, Korea. jwhuh@paik.ac.kr
authors.forename: Jin Won
authors.initials: JW
authors.lastname: Huh
authors.forename: Hoon
authors.initials: H
authors.lastname: Jung
authors.forename: Hye Sook
authors.initials: HS
authors.lastname: Choi
authors.forename: Sang-Bum
authors.initials: SB
authors.lastname: Hong
authors.forename: Chae-Man
authors.initials: CM
authors.lastname: Lim
authors.forename: Younsuck
authors.initials: Y
authors.lastname: Koh
mesh_terms: D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011175:Positive-Pressure Respiration / Q000379:methods*; D011650:Pulmonary Alveoli / Q000502:physiology*; D012128:Respiratory Distress Syndrome / Q000503:physiopathology* / Q000628:therapy*; D015656:Respiratory Mechanics / Q000502:physiology; D017186:Titrimetry / Q000379:methods