IMPORTANCE: Perioperative lung-protective ventilation has been recommended to reduce pulmonary complications after cardiac surgery. The protective role of a small tidal volume (VT) has been established, whereas the added protection afforded by alveolar recruiting strategies remains controversial. OBJECTIVE: To determine whether an intensive alveolar recruitment strategy could reduce postoperative pulmonary complications, when added to a protective ventilation with small VT. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial of patients with hypoxemia after cardiac surgery at a single ICU in Brazil (December 2011 to 2014). INTERVENTIONS: Intensive recruitment strategy (n = 157) or moderate recruitment strategy (n = 163) plus protective ventilation with small VT. MAIN OUTCOMES AND MEASURES: Severity of postoperative pulmonary complications computed until hospital discharge, analyzed with a common odds ratio (OR) to detect ordinal shift in distribution of pulmonary complication severity score (0-to-5 scale, 0, no complications; 5, death). Prespecified secondary outcomes were length of stay in the ICU and hospital, incidence of barotrauma, and hospital mortality. RESULTS: All 320 patients (median age 62 years; IQR 56 to 69 years; 125 women (39%)) completed the trial. The intensive recruitment strategy group had a mean 1.8 (95% CI 1.7 to 2.0) and a median 1.7 (IQR 1.0 to 2.0) pulmonary complications score versus 2.1 (95% CI 2.0 to 2.3) and 2.0 (IQR 1.5 to 3.0) for the moderate strategy group. Overall, the distribution of primary outcome scores shifted consistently in favor of the intensive strategy, with a common OR for lower scores of 1.86 (95% CI 1.22 to 2.83; p = 0.003). The mean hospital stay for the moderate group was 12.4 days versus 10.9 days in the intensive group (absolute difference -1.5 days; 95% CI -3.1 to -0.3; p = 0.04). The mean ICU stay for the moderate group was 4.8 days versus 3.8 days for the intensive group (absolute difference -1.0 days; 95% CI -1.6 to -0.2; p = 0.01). Hospital mortality (2.5% in the intensive group versus 4.9% in the moderate group; absolute difference -2.4%, 95% CI -7.1% to 2.2%) and barotrauma incidence (0% in the intensive group versus 0.6% in the moderate group; absolute difference -0.6%; 95% CI -1.8% to 0.6%; p = 0.51) did not differ significantly between groups. CONCLUSIONS AND RELEVANCE: Among patients with hypoxemia after cardiac surgery, the use of an intensive versus a moderate alveolar recruitment strategy resulted in less severe pulmonary complications while in the hospital. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT01502332.

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