Mechanical Ventilation in ARDS* A State-of-the-Art Review

Mechanical ventilation is an essential component of the care of patients with ARDS, and a large number of randomized controlled clinical trials have now been conducted evaluating the efficacy and safety of various methods of mechanical ventilation for the treatment of ARDS. Low tidal volume ventilation (< 6 mL/kg predicted body weight) should be utilized in all patients with ARDS as it is the only method of mechanical ventilation that, to date, has been shown to improve survival. High positive end-expiratory pressure, alveolar recruitment maneuvers, and prone positioning may each be useful as rescue therapy in a patient with severe hypoxemia, but these methods of ventilation do not improve survival for the wide population of patients with ARDS. Although not specific to the treatment of ARDS, protocol-driven weaning that utilizes a daily spontaneous breathing trial and ventilation in the semirecumbent position have proven benefits and should be used in the management of ARDS patients. (CHEST 2007; 131:921–929) Key words: acute lung injury; ARDS; mechanical ventilation; positive end-expiratory pressure; prone position; tidal volumes Abbreviations: ALI acute lung injury; ALVEOLI Assessment of Low Tidal Volume and Elevated End-Expiratory Pressure To Obviate Lung Injury; APACHE acute physiology and chronic health evaluation; APRV airway pressur