Ventilation of patients with acute lung injury and acute respiratory distress syndrome: Has new evidence changed clinical practice?

Objectives: A recent randomized trial of mechanical ventilation in acute lung injury (ALI)/adult respiratory distress syndrome (ARDS) demonstrated a 22% relative reduction in mortality rate using 6 mL/kg predicted body weight tidal volume vs. 12 mL/kg predicted body weight tidal volume. We determined whether publication of these findings changed clinical practice. Design: Retrospective cohort, 12 months before (Pre) and 12 months after publication (Post) of a randomized trial supporting the use of a 6 mUkg predicted body weight tidal volume strategy. Setting:Three tertiary care hospitals in northern New England. Patients: From a sample of 943 patients receiving prolonged mechanical ventilation between 1998 and 1999 (Pre) and between 2000 and 2001 (Post), 300 patients meeting the American-European Consensus Conference definition of ALI or ARDS were selected for analysis. Interventions: The tidal volume, tidal volume/kg predicted body weight, and proportion receiving tidal volume/kg greater than or equal to 6 mUkg and less than or equal to 12 mL/kg predicted body weight were recorded at noon the first day after the diagnosis of ALI or ARDS was established. Measurements and Main Results: Pre and Post mean tidal volume (+/- SD) size and tidal volume size/kg predicted body weight were 759 +/- 158 ml. (median 750 mL) vs. 639 +/- 138 ml. (median 600 mL, p < .001) and 12.3 +/- 2.7 mUkg (median 11.7 mL/kg) vs. 10.6 +/- 2.4 mL/kg (median 10.7 mL/kg, p < .001) respectively. Pre and Post plateau pressures and peak airway pressures were similar. Conclusion: Publication of a trial demonstrating large mortality reductions using small tidal volume was associated with significant reductions in tidal volume delivered to patients with ALI/ARDS. However, wide variation in practice persists, and the proportion of patients receiving tidal volumes within recommended limits (-8 mL/kg) remains modest.