Among patients with moderate to severe acute respiratory distress syndrome (ARDS), lung recruitment and titrated positive end-expiratory pressure (PEEP) are associated with higher 28-day mortality rates compared with use of a conventional low PEEP strategy, according to the results of a multicenter, randomized clinical trial published in the Journal of the American Medical Association.

The study, conducted at 120 intensive care units (ICUs) in 9 countries between November 17, 2011, and April 25, 2017, enrolled and followed a total of 1010 patients with moderate to severe ARDS of <72 hours’ duration. Patients were randomly assigned in a 1:1 ratio to either an experimental strategy with a lung recruitment maneuver and PEEP titrated according to the best respiratory-system compliance (n=501; experimental group) or a low PEEP strategy (n=509; control group). All participants received volume-assist control ventilation until they were weaned.

The primary outcome was all-cause mortality until 28 days. Secondary outcomes included length of ICU and hospital stay, number of ventilator-free days from day 1 to day 28, pneumothorax requiring drainage within 7 days, barotrauma within 7 days, and ICU, in-hospital, and 6-month mortality.

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At 28 days, 55.3% of patients (277 of 501) in the experimental arm and 49.3% of patients (251 of 509) in the control arm had died (hazard ratio [HR], 1.20; 95% CI, 1.01-1.42; P =.041). All-cause mortality was also significantly higher within 6 months in the experimental vs the control group (65.3% vs 59.9%, respectively; HR, 1.18; 95% CI, 1.01-1.38; P =.04).

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Significant differences were also observed between the experimental and control groups with respect to mean number of ventilator-free days through day 28 (5.3 days vs 6.4 days, respectively; 95% CI, –2.1 to –0.1; P =.03); pneumothorax requiring drainage within 7 days (3.2% vs 1.2%, respectively; 95% CI, 0.2-3.8; P =.03); and barotrauma within 7 days (5.6% vs 1.6%; 95% CI, 1.5-6.5; P =.001).

No significant differences between the groups were reported with respect to length of ICU stay, length of hospitalization, ICU mortality rate, or in-hospital mortality rate.

The investigators concluded that the study findings do not support the routine use of a lung recruitment maneuver and PEEP titration in patients with moderate to severe ARDS, as increased mortality rates were reported with this experimental therapy.


Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators; Cavalcanti AB, Suzumura ÉA, Laranjeira LN, et al. 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. JAMA. 2017;318(14):1335-1345.