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ARDS Clinical Trials Network. Effects of recruitment maneuvers in patients with acute lung injury and acute respiratory distress syndrome ventilated with high positive end-expiratory pressure
Brower RG, Morris A, MacIntyre N, Matthay MA, Hayden D, Thompson T, Clemmer T, Lanken PN, Schoenfeld D, ARDS Clinical Trials Network, National Heart Lung and Blood Institute, National Institutes of Health
Critical Care Medicine 2003 Nov;31(11):2592-2597
clinical trial
3/10 [Eligibility criteria: No; Random allocation: Yes; Concealed allocation: No; Baseline comparability: No; Blind subjects: No; Blind therapists: No; Blind assessors: No; Adequate follow-up: No; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates and variability: Yes. Note: Eligibility criteria item does not contribute to total score] *This score has been confirmed*

OBJECTIVE: Positive end-expiratory pressure (PEEP) and recruitment maneuvers (RMs) may partially reverse atelectasis and reduce ventilation-associated lung injury. The purposes of this study were to assess (a) magnitude and duration of RM effects on arterial oxygenation and on requirements for oxygenation support (Fio2/PEEP) in patients with acute lung injury and acute respiratory distress syndrome (ALI/ARDS) receiving ventilation with low tidal volumes and high levels of PEEP; and (b) frequency of adverse respiratory and circulatory events attributable to RMs. DESIGN: Prospective, randomized, crossover study. SETTING: Thirty-four intensive care units at 19 hospitals. PATIENTS: Seventy-two patients with early ALI/ARDS. Baseline PEEP and FiO2 were 13.8 +/- 3.0 cmH2O and 0.39 +/- 0.10, respectively (mean +/- SD). INTERVENTIONS: We conducted RMs by applying continuous positive airway pressure of 35 to 40 cmH2O for 30 secs. We conducted sham RMs on alternate days. We monitored oxyhemoglobin saturation by pulse oximetry (SpO2), FiO2/PEEP, blood pressure, and heart rate for 8 hrs after RMs and sham RMs. We examined chest radiographs for barotrauma. MEASUREMENTS AND MAIN RESULTS: Responses to RMs were variable. Greatest increments from baseline SpO2 within 10 mins after RMs were larger than after sham RMs (1.7 +/- 0.2 versus 0.6 +/- 0.3%, mean +/- SEM, p < 0.01). Systolic blood pressure decreased more +/- 1.1 mmHg, p < 0.01). Changes in FiO2/PEEP requirements were not significantly different at any time after RMs versus sham RMs. Barotrauma was apparent on first radiographs after one RM and one sham RM. CONCLUSIONS: In ALI/ARDS patients receiving mechanical ventilation with low tidal volumes and high PEEP, short-term effects of RMs as conducted in this study are variable. Beneficial effects on gas exchange in responders appear to be of brief duration. More information is needed to determine the role of recruitment maneuvers in the management of ALI/ARDS.

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