title: Tidal volume and plateau pressure use for acute lung injury from 2000 to present: a systematic literature review.
abstract: OBJECTIVE
  Since publication of the Respiratory Management of Acute Lung Injury and Acute Respiratory Distress Syndrome (ARMA) trial in 2000, use of tidal volume (VT) less than or equal to 6 mL/kg predicted body weight with corresponding plateau airway pressures (PPlat) less than or equal to 30 cm H2O has been advocated for acute lung injury. However, compliance with these recommendations is unknown. We therefore investigated VT (mL/kg predicted body weight) and PPlat (cm H2O) practices reported in studies of acute lung injury since ARMA using a systematic literature review (i.e., not a meta-analysis).
  
  
  METHODS
  PubMed, Scopus, and EMBASE.
  
  
  METHODS
  Randomized controlled trials and nonrandomized studies enrolling patients with acute lung injury from May 2000 to June 2013 and reporting VT.
  
  
  METHODS
  Whether the study was a randomized controlled trial or a nonrandomized study and performed or not at an Acute Respiratory Distress Syndrome Network center; in randomized controlled trials, the pre- and postrandomization VT (mL/kg predicted body weight) and PPlat (cm H2O) and whether a VT protocol was used postrandomization; in nonrandomized studies, baseline VT and PPlat.
  
  
  RESULTS
  Twenty-two randomized controlled trials and 71 nonrandomized studies were included. Since 2000 at acute respiratory distress syndrome Network centers, routine VT was similar comparing randomized controlled trials and nonrandomized studies (p = 0.25) and unchanged over time (p = 0.75) with a mean value of 6.81 (95% CI, 6.45, 7.18). At non-acute respiratory distress syndrome Network centers, routine VT was also similar when comparing randomized controlled trials and nonrandomized studies (p = 0.71), but decreased (p = 0.001); the most recent estimate for it was 6.77 (6.22, 7.32). All VT estimates were significantly greater than 6 (p ≤ 0.02). In randomized controlled trials employing VT protocols, routine VT was reduced in both acute respiratory distress syndrome Network (n = 4) and non-acute respiratory distress syndrome Network (n = 11) trials (p ≤ 0.01 for both), but even postrandomization was greater than 6 (6.47 [6.29, 6.65] and 6.80 [6.42, 7.17], respectively; p ≤ 0.0001 for both). In 59 studies providing data, routine PPlat, averaged across acute respiratory distress syndrome Network or non-acute respiratory distress syndrome Network centers, was significantly less than 30 (p ≤ 0.02).
  
  
  CONCLUSIONS
  For clinicians treating acute lung injury since 2000, achieving VT less than or equal to 6 mL/kg predicted body weight may not have been as attainable or important as PPlat less than or equal to 30 cm H2O. If so, there may be equipoise to test if VT less than or equal to 6 mL/kg predicted body weight are necessary to improve acute lung injury outcome.
authors.affiliation: 1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD. 2National Institutes of Health Library, National Institutes of Health, Bethesda, MD.
authors.forename: Dharmvir S
authors.initials: DS
authors.lastname: Jaswal
authors.forename: Janice M
authors.initials: JM
authors.lastname: Leung
authors.forename: Junfeng
authors.initials: J
authors.lastname: Sun
authors.forename: Xizhong
authors.initials: X
authors.lastname: Cui
authors.forename: Yan
authors.initials: Y
authors.lastname: Li
authors.forename: Steven
authors.initials: S
authors.lastname: Kern
authors.forename: Judith
authors.initials: J
authors.lastname: Welsh
authors.forename: Charles
authors.initials: C
authors.lastname: Natanson
authors.forename: Peter Q
authors.initials: PQ
authors.lastname: Eichacker
mesh_terms: D055371:Acute Lung Injury / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D012121:Respiration, Artificial / Q000009:adverse effects / Q000379:methods*; D012128:Respiratory Distress Syndrome / Q000209:etiology / Q000517:prevention & control; D013990:Tidal Volume / Q000502:physiology*
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