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ART

Effect of Lung Recruitment and Titrated PEEP vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome

JAMA, 2017 · Multicenter, randomized controlled trial in 120 intensive care units across 9 countries (Alveolar Recruitment for ARDS Trial investigators)

Clinical question

Does an aggressive lung recruitment maneuver strategy with titrated PEEP reduce mortality in moderate-to-severe ARDS, compared with a conventional low-PEEP strategy?

Population: 1,010 adult patients with moderate-to-severe ARDS (PaO2/FiO2 <= 200 mmHg) on mechanical ventilation < 72 hours.
Inclusion criteria: Moderate-to-severe ARDS by Berlin definition
Mechanically ventilated for less than 72 hours
PaO2/FiO2 ratio <= 200 mmHg with PEEP >= 10 cmH2O and FiO2 >= 0.50
Intervention: A stepwise lung recruitment maneuver protocol (PEEP escalated up to 45 cmH2O and airway pressure up to 60 cmH2O) followed by decremental PEEP titration to best respiratory-system static compliance + 2 cmH2O.
Comparator: Conventional low-PEEP lung-protective ventilation (ARDSNet-style table targeting SpO2 88-95%).
Primary outcome: 28-day all-cause mortality.
Secondary outcomes: Length of ICU and hospital stay
Ventilator-free days through day 28
Pneumothorax or barotrauma requiring drainage within 7 days
6-month all-cause mortality
Result: The aggressive recruitment and titrated-PEEP strategy was associated with significantly higher 28-day mortality (55.3% vs 45.3%) and increased barotrauma compared with conventional low-PEEP. (HR 1.20 (95% CI 1.03-1.39); 28-day mortality 55.3% (279/501) vs 45.3% (231/509), P = 0.041)

What the trial found

In moderate-to-severe ARDS, an aggressive lung recruitment maneuver and titrated-PEEP strategy resulted in worse 28-day survival (55.3% vs 45.3%, P=0.041), higher 6-month mortality (65.3% vs 59.9%, P=0.04), and increased pneumothorax requiring chest tube drainage (5.6% vs 1.6%, P=0.001).

Current guideline position

Current ATS/ESICM ARDS guidelines recommend against routine aggressive stepwise lung recruitment maneuvers and caution against excessive PEEP titration in unselected ARDS patients.

Clinical interpretation

ART demonstrates that aggressive staircase recruitment maneuvers up to 60 cmH2O and high compliance-titrated PEEP cause hemodynamic collapse and barotrauma that outweigh alveolar recruitment benefit. Routine high-pressure recruitment maneuvers are harmful and not recommended.

Limitations

Unblinded design, unavoidable in ventilator strategy trials.
Recruitment maneuver tested was particularly aggressive (airway pressures up to 60 cmH2O), which may not represent gentler brief recruitment maneuvers.
High baseline mortality across study centers (45-55%).

High certainty

Clinical Context & Relevant Topics (1)

Disease Reference

Acute Respiratory Distress Syndrome

Acute, diffuse inflammatory lung injury causing hypoxemia and bilateral infiltrates not fully explained by cardiac failure or fluid overload.

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