title: Lower tidal volume strategy (≈3 ml/kg) combined with extracorporeal CO2 removal versus 'conventional' protective ventilation (6 ml/kg) in severe ARDS: the prospective randomized Xtravent-study.
abstract: BACKGROUND
  Acute respiratory distress syndrome is characterized by damage to the lung caused by various insults, including ventilation itself, and tidal hyperinflation can lead to ventilator induced lung injury (VILI). We investigated the effects of a low tidal volume (V(T)) strategy (V(T) ≈ 3 ml/kg/predicted body weight [PBW]) using pumpless extracorporeal lung assist in established ARDS.
  
  
  METHODS
  Seventy-nine patients were enrolled after a 'stabilization period' (24 h with optimized therapy and high PEEP). They were randomly assigned to receive a low V(T) ventilation (≈3 ml/kg) combined with extracorporeal CO2 elimination, or to a ARDSNet strategy (≈6 ml/kg) without the extracorporeal device. The primary outcome was the 28-days and 60-days ventilator-free days (VFD). Secondary outcome parameters were respiratory mechanics, gas exchange, analgesic/sedation use, complications and hospital mortality.
  
  
  RESULTS
  Ventilation with very low V(T)'s was easy to implement with extracorporeal CO2-removal. VFD's within 60 days were not different between the study group (33.2 ± 20) and the control group (29.2 ± 21, p = 0.469), but in more hypoxemic patients (PaO2/FIO2 ≤150) a post hoc analysis demonstrated significant improved VFD-60 in study patients (40.9 ± 12.8) compared to control (28.2 ± 16.4, p = 0.033). The mortality rate was low (16.5%) and did not differ between groups.
  
  
  CONCLUSIONS
  The use of very low V(T) combined with extracorporeal CO2 removal has the potential to further reduce VILI compared with a 'normal' lung protective management. Whether this strategy will improve survival in ARDS patients remains to be determined (Clinical trials NCT 00538928).
authors.affiliation: Department of Anesthesia and Operative Intensive Care, Regensburg University Hospital, Regensburg, Germany. thomas.bein@klinik.uni-regensburg.de
authors.forename: Thomas
authors.initials: T
authors.lastname: Bein
authors.forename: Steffen
authors.initials: S
authors.lastname: Weber-Carstens
authors.forename: Anton
authors.initials: A
authors.lastname: Goldmann
authors.forename: Thomas
authors.initials: T
authors.lastname: Müller
authors.forename: Thomas
authors.initials: T
authors.lastname: Staudinger
authors.forename: Jörg
authors.initials: J
authors.lastname: Brederlau
authors.forename: Ralf
authors.initials: R
authors.lastname: Muellenbach
authors.forename: Rolf
authors.initials: R
authors.lastname: Dembinski
authors.forename: Bernhard M
authors.initials: BM
authors.lastname: Graf
authors.forename: Marlene
authors.initials: M
authors.lastname: Wewalka
authors.forename: Alois
authors.initials: A
authors.lastname: Philipp
authors.forename: Klaus-Dieter
authors.initials: KD
authors.lastname: Wernecke
authors.forename: Matthias
authors.initials: M
authors.lastname: Lubnow
authors.forename: Arthur S
authors.initials: AS
authors.lastname: Slutsky
mesh_terms: D000465:Algorithms; D000700:Analgesics / Q000627:therapeutic use; D016009:Chi-Square Distribution; D005260:Female; D006305:Health Status Indicators; D017052:Hospital Mortality; D006801:Humans; D006935:Hypercapnia / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D011175:Positive-Pressure Respiration / Q000379:methods*; D011446:Prospective Studies; D012128:Respiratory Distress Syndrome / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D015656:Respiratory Mechanics; D018709:Statistics, Nonparametric; D013990:Tidal Volume; D016896:Treatment Outcome; D015300:Ventilator Weaning
chemical_list: D000700:Analgesics; D006993:Hypnotics and Sedatives