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Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial

Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators , Cavalcanti AB 1 , Suzumura ÉA 1 , Laranjeira LN 1 , Paisani DM 1 , Damiani LP 1 Show all authors , Guimarães HP 1 , Romano ER 1 , Regenga MM 1 , Taniguchi LNT 1 , Teixeira C 2 , Pinheiro de Oliveira R 3 , Machado FR 4 , Diaz-Quijano FA 5 , Filho MSA 6 , Maia IS 7 , Caser EB 8 , Filho WO 9 , Borges MC 10 , Martins PA 11 , Matsui M 12 , Ospina-Tascón GA 13 , Giancursi TS 14 , Giraldo-Ramirez ND 15 , Vieira SRR 16 , Assef MDGPL 17 , Hasan MS 18 , Szczeklik W 19 , Rios F 20 , Amato MBP 21 , Berwanger O 1 , Ribeiro de Carvalho CR 21

Affiliations 

  • 1 HCor Research Institute, São Paulo, Brazil
  • 2 Hospital Moinhos de Vento, Porto Alegre, Brazil
  • 3 Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
  • 4 Anesthesiology, Pain, and Intensive Care Department, Federal University of São Paulo-UNIFESP, São Paulo, Brazil
  • 5 Epidemiology Department, School of Public Health, University of São Paulo, São Paulo, Brazil
  • 6 Hospital Maternidade São Vicente de Paulo, Barbalha, Brazil
  • 7 Hospital Nereu Ramos, Florianópolis, Brazil
  • 8 Hospital Unimed Vitória, Vitória, Brazil
  • 9 Hospital e Pronto-Socorro 28 de Agosto, Manaus, Brazil
  • 10 Unidade de Emergência do Hospital das Clínicas da FMRP-USP, Ribeirão Preto, Brazil
  • 11 Hospital Estadual Dr Jayme dos Santos Neves, Serra, Brazil
  • 12 Hospital Universitário da Universidade Federal da Grande Dourados, Dourados, Brazil
  • 13 Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Cali, Colombia
  • 14 Hospital Universitário do Oeste do Paraná, Cascavel, Brazil
  • 15 Hospital Pablo Tóbon Uribe, Medellín, Colombia
  • 16 Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
  • 17 Hospital Regional Hans Dieter Schmidt, Joinville, Brazil
  • 18 University Malaya Medical Centre, Kuala Lumpur, Malaysia
  • 19 Jagiellonian University Medical College; Department of Intensive Care and Perioperative Medicine, Krakow, Poland
  • 20 Hospital Nacional Alejandro Posadas, Moron, Argentina
  • 21 Cardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), University of São Paulo, São Paulo, Brazil
JAMA, 2017 10 10;318(14):1335-1345.
PMID: 28973363 DOI: 10.1001/jama.2017.14171

Abstract

Importance: The effects of recruitment maneuvers and positive end-expiratory pressure (PEEP) titration on clinical outcomes in patients with acute respiratory distress syndrome (ARDS) remain uncertain.

Objective: To determine if lung recruitment associated with PEEP titration according to the best respiratory-system compliance decreases 28-day mortality of patients with moderate to severe ARDS compared with a conventional low-PEEP strategy.

Design, Setting, and Participants: Multicenter, randomized trial conducted at 120 intensive care units (ICUs) from 9 countries from November 17, 2011, through April 25, 2017, enrolling adults with moderate to severe ARDS.

Interventions: An experimental strategy with a lung recruitment maneuver and PEEP titration according to the best respiratory-system compliance (n = 501; experimental group) or a control strategy of low PEEP (n = 509). All patients received volume-assist control mode until weaning.

Main Outcomes and Measures: The primary outcome was all-cause mortality until 28 days. Secondary outcomes were length of ICU and hospital stay; ventilator-free days through day 28; pneumothorax requiring drainage within 7 days; barotrauma within 7 days; and ICU, in-hospital, and 6-month mortality.

Results: A total of 1010 patients (37.5% female; mean [SD] age, 50.9 [17.4] years) were enrolled and followed up. At 28 days, 277 of 501 patients (55.3%) in the experimental group and 251 of 509 patients (49.3%) in the control group had died (hazard ratio [HR], 1.20; 95% CI, 1.01 to 1.42; P = .041). Compared with the control group, the experimental group strategy increased 6-month mortality (65.3% vs 59.9%; HR, 1.18; 95% CI, 1.01 to 1.38; P = .04), decreased the number of mean ventilator-free days (5.3 vs 6.4; difference, -1.1; 95% CI, -2.1 to -0.1; P = .03), increased the risk of pneumothorax requiring drainage (3.2% vs 1.2%; difference, 2.0%; 95% CI, 0.0% to 4.0%; P = .03), and the risk of barotrauma (5.6% vs 1.6%; difference, 4.0%; 95% CI, 1.5% to 6.5%; P = .001). There were no significant differences in the length of ICU stay, length of hospital stay, ICU mortality, and in-hospital mortality.

Conclusions and Relevance: In patients with moderate to severe ARDS, a strategy with lung recruitment and titrated PEEP compared with low PEEP increased 28-day all-cause mortality. These findings do not support the routine use of lung recruitment maneuver and PEEP titration in these patients.

Trial Registration: clinicaltrials.gov Identifier: NCT01374022.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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