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Randomized Controlled Trial
. 2011;15(3):R133.
doi: 10.1186/cc10249. Epub 2011 Jun 2.

A randomised controlled trial of an open lung strategy with staircase recruitment, titrated PEEP and targeted low airway pressures in patients with acute respiratory distress syndrome

Carol L Hodgson  1 , David V Tuxen, Andrew R Davies, Michael J Bailey, Alisa M Higgins, Anne E Holland, Jenny L Keating, David V Pilcher, Andrew J Westbrook, David J Cooper, Alistair D Nichol
Affiliations
Randomized Controlled Trial

A randomised controlled trial of an open lung strategy with staircase recruitment, titrated PEEP and targeted low airway pressures in patients with acute respiratory distress syndrome

Carol L Hodgson et al. Crit Care. 2011.

Abstract

Introduction: Tidal volume and plateau pressure minimisation are the standard components of a protective lung ventilation strategy for patients with acute respiratory distress syndrome (ARDS). Open lung strategies, including higher positive end-expiratory pressure (PEEP) and recruitment manoeuvres to date have not proven efficacious. This study examines the effectiveness and safety of a novel open lung strategy, which includes permissive hypercapnia, staircase recruitment manoeuvres (SRM) and low airway pressure with PEEP titration.

Method: Twenty ARDS patients were randomised to treatment or ARDSnet control ventilation strategies. The treatment group received SRM with decremental PEEP titration and targeted plateau pressure < 30 cm H2O. Gas exchange and lung compliance were measured daily for 7 days and plasma cytokines in the first 24 hours and on days 1, 3, 5 and 7 (mean ± SE). Duration of ventilation, ICU stay and hospital stay (median and interquartile range) and hospital survival were determined.

Results: There were significant overall differences between groups when considering plasma IL-8 and TNF-α. For plasma IL-8, the control group was 41% higher than the treatment group over the seven-day period (ratio 1.41 (1.11 to 1.79), P = 0.01), while for TNF-α the control group was 20% higher over the seven-day period (ratio 1.20 (1.01 to 1.42) P = 0.05). PaO2/FIO2 (204 ± 9 versus 165 ± 9 mmHg, P = 0.005) and static lung compliance (49.1 ± 2.9 versus 33.7 ± 2.7 mls/cm H2O, P < 0.001) were higher in the treatment group than the control group over seven days. There was no difference in duration of ventilation (180 (87 to 298) versus 341 (131 to 351) hrs, P = 0.13), duration of ICU stay (9.9 (5.6 to 14.8) versus 16.0 (8.1 to 19.3) days, P = 0.19) and duration of hospital stay (17.9 (13.7 to 34.5) versus 24.7 (20.5 to 39.8) days, P = 0.16) between the treatment and control groups.

Conclusions: This open lung strategy was associated with greater amelioration in some systemic cytokines, improved oxygenation and lung compliance over seven days. A larger trial powered to examine clinically-meaningful outcomes is warranted.

Trial registration: ACTRN12607000465459.

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Figures

Figure 1
Figure 1
Patient flow diagram. AAA, abdominal aortic aneurysm; COPD, chronic obstructive lung disease; ICP, intracranial pressure; PaO2/FIO2, partial pressure of oxygen to inspired fraction of oxygen ratio.
Figure 2
Figure 2
IL-8 and TNF-α measured over 168 hours (seven days) reported as geometric means (95% CI). There was a significant overall difference in interleukin-8 and serum tumour necrosis factor-alpha between the treatment group and the control group over the seven-day period (P = 0.01 and P = 0.05 respectively).
Figure 3
Figure 3
Static lung compliance measured in ventilated patients for seven days (mean ± SE). There was a significant overall improvement in static lung compliance in the PHARLAP group compared to control group patients. A = missing data analysed as random P = 0.001, B = last observation carried forward P = 0.01.
Figure 4
Figure 4
PaO2/FIO2 measured over the first 24 hours in ventilated patients (mean ± SE). PHARLAP group had a significant overall increase in PaO2/FIO2 compared to control group patients (*P < 0.01).
Figure 5
Figure 5
PaO2/FIO2 measured over seven days in ventilated patients (mean ± SE). There was a significant overall improvement in PaO2/FIO2 ratio in PHARLAP compared to control group patients. A = missing data analysed as random, P = 0.005. B = last observation carried forward, P = 0.03.
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