1. Protective Lung Strategy Mazen Kherallah, MD, FCCP

2. Conventional Vs Protective

3. Actuarial 28-Day Survival among 53 Patients with the Acute Respiratory Distress Syndrome Assigned to Protective or Conventional Mechanical Ventilation
Figure 1. Actuarial 28-Day Survival among 53 Patients with the Acute Respiratory Distress Syndrome Assigned to Protective or Conventional Mechanical Ventilation. The data are based on an intention-to-treat analysis. The P value indicates the effect of ventilatory treatment as estimated by the Cox regression model, with the risk of death associated with the adjusted base-line score on APACHE II included as a covariate.
Amato M et al. N Engl J Med 1998;338:

4. VENTILATION WITH LOWER TIDAL VOLUMES AS COMPARED WITH
TRADITIONAL TIDAL VOLUMES FOR ACUTE LUNG INJURY
AND THE ACUTE RESPIRATORY DISTRESS SYNDROME
Table 4. Main Outcome Variables.
.ARDSnet N Engl J Med 2000;342:

5. NIH ARDS Network Trial Mechanical Ventilation in ARDS
P = 0.007
ARDSnet N Engl J Med 2000;342:

6. SUMMARY OF RANDOMIZED CONTROLLED TRIALS OF VOLUME- AND PRESSURE-LIMITED MECHANICAL VENTILATION
Hager DN et al . Am J RespirCrit Care Med 172:1241–1245

7. High PEEP Low Tidal Volume

8. A high PEEP-low tidal volume ventilatory strategy improves outcome in persistent ARDS
Villar et al May;34(5):1311-8

9. LOVS Study Lung Open Ventilation Study

10. Results of 3 Trials of Aggressive vs Conservative PEEP
ALVEOLI
LOVS
ExPress N
583
983
767
Aggressive PEEP
15 cm H2O*
13 cm H2O*
PaO2/FiO2
222 mm Hg*
187 mm Hg*
218 mm Hg*
Pplat
27 cm H2O*
30 cm H2O*
Mortality
27%
36%
28%
Conservative PEEP
8 cm H2O*
9 cm H2O*
7 cm H2O*
168 mm Hg*
149 mm Hg*
150 mm Hg*
24 cm H2O*
25 cm H2O*
21 cm H2O*
25%
40% 31

11. Prone Position

12. Kaplan-Meier Estimates of Survival at Six Months
Figure 1. Kaplan-Meier Estimates of Survival at Six Months. The status at 183 days was known for all but seven patients (four in the prone group and three in the supine group). The difference between groups was not significant (P=0.65 by the log-rank test).
Gattinoni L et al. N Engl J Med 2001;345:

13. Changes in Respiratory Variables during the 10-Day Treatment Period
Table 2. Changes in Respiratory Variables during the 10-Day Treatment Period.
Gattinoni L et al. N Engl J Med 2001;345:

14. Incidence of Complications
Table 2. Changes in Respiratory Variables during the 10-Day Treatment Period.
Gattinoni L et al. N Engl J Med 2001;345:

15. A Multicenter Trial of Prolonged Prone Ventilation in
Severe Acute Respiratory Distress Syndrome
mean of 17 h/d for a mean of 10 d.
Mancebo J, et al.Am J Respir Crit Care Med 173:1233–1239

16. Semirecumbent Position

17. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomized trial
86 patients: 95% CI for difference , p=0.003).
. Drakulovic MB 1999 Nov 27;354(9193):

18. Noninvasive Ventilation in ALI/ARDS with mild/moderate Hypoxemic Respiratory Failure

19. Antonelli M et al. N Engl J Med 1998;339:429-435
The Ratio of the Partial Pressure of Arterial Oxygen to the Fraction of Inspired Oxygen (PaO2:FiO2) at Base Line and after One Hour of Mechanical Ventilation in Patients with Acute Respiratory Failure in the Noninvasive-Ventilation and Conventional-Ventilation Groups
Figure 1. The Ratio of the Partial Pressure of Arterial Oxygen to the Fraction of Inspired Oxygen (PaO2:FiO2) at Base Line and after One Hour of Mechanical Ventilation in Patients with Acute Respiratory Failure in the Noninvasive-Ventilation and Conventional-Ventilation Groups. A paired t-test was used for the statistical comparison. The degree of improvement in gas exchange after the start of mechanical ventilation was similar in the two groups. The values shown within the panels are means {+/-}SD.
Antonelli M et al. N Engl J Med 1998;339:

20. Serious Complications
Figure 1. The Ratio of the Partial Pressure of Arterial Oxygen to the Fraction of Inspired Oxygen (PaO2:FiO2) at Base Line and after One Hour of Mechanical Ventilation in Patients with Acute Respiratory Failure in the Noninvasive-Ventilation and Conventional-Ventilation Groups. A paired t-test was used for the statistical comparison. The degree of improvement in gas exchange after the start of mechanical ventilation was similar in the two groups. The values shown within the panels are means {+/-}SD.
Antonelli M et al. N Engl J Med 1998;339:

21. Protocolized Weaning with Spontaneous Breathing Trials

22. Effect on the Duration of Mechanical Ventilation of Identifying Patients Capable of Breathing Spontaneously
Figure 1. Kaplan-Meier Analysis of the Duration of Mechanical Ventilation after a Successful Screening Test. After adjustment for the severity of illness at base line (as measured by the APACHE II score), age, sex, race, location of the intensive care unit, and duration of intubation before enrollment, a Cox proportional-hazards analysis showed that mechanical ventilation was discontinued more rapidly in the intervention group than in the control group (relative risk of successful extubation, 2.13; 95 percent confidence interval, 1.55 to 2.92; P
Ely E et al. N Engl J Med 1996;335:

23. Comparison of Outcomes between Study Groups
Table 2. Comparison of Outcomes between Study Groups.
Ely E et al. N Engl J Med 1996;335:

24. No Routine Use of PAC

25. Pulmonary-Artery versus Central Venous Catheter to Guide Treatment of Acute Lung Injury
Volume 354;21: May 25, 2006

26. Catheter-Related Complications

27. Conservative Fluid Strategy in Patient with no Tissue Hypoperfusion

28. Comparison of Two Fluid-Management Strategies in Acute Lung Injury
The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network N Engl J Med 2006;354:

29. Probability of Survival to Hospital Discharge and of Breathing without Assistance during the First 60 Days after Randomization
The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network N Engl J Med 2006;354:

30. Ventilatory Support
Target a tidal volume of 6ml/kg (predicted) body weight in patients with ALI/ARDS. (1B)
Target an initial upper limit plateau pressure ≤30 cmH2O. Consider chest wall compliance when assessing plateau pressure. (1C)
Allow PaCO2 to increase above normal, if needed to minimize plateau pressures and tidal volumes. (1C)
Positive end expiratory pressure (PEEP) should be set to avoid extensive lung collapse at end expiration. (1C)
Consider using the prone position for ARDS patients requiring potentially injurious levels of FiO2 or plateau pressure, provided they are not put at risk from positional changes. (2C)
Maintain mechanically ventilated patients in a semi-recumbent position (head of the bed raised to 45 ◦) unless contraindicated (1B), between 30◦–45◦ (2C).
Non invasive ventilation may be considered in the minority of ALI/ARDS patients with mild-moderate hypoxemic respiratory failure.
Use a weaning protocol and a spontaneous breathing trial (SBT) regularly to evaluate the potential for discontinuing mechanical ventilation. (1A)
Do not use a PAC for the routine monitoring of patients with ALI/ARDS. (1A)