BACKGROUND: Low-tidal-volume ventilation may be associated with repetitive opening and closing of terminal airways. The use of PEEP is intended to keep the alveoli open. No method of adjusting the optimal PEEP has shown to be superior or to improve clinical outcomes. We conducted a pilot study to evaluate the effect of setting an individualized level of PEEP at the highest compliance on oxygenation, multiple-organ-dysfunction, and survival in subjects with ARDS. METHODS: Subjects with ARDS ventilated with low tidal volumes and limitation of airway pressure to 30 cm H 2 O were randomized to either a compliance-guided PEEP group or an F IO 2 -guided group. RESULTS: Of the 159 patients with ARDS admitted during the study period, 70 met the inclusion criteria. Subjects in the compliance-guided group showed nonsignificant improvements in P aO 2 /F IO 2 during the first 14 days, and in 28-day mortality (20.6% vs. 38.9%, P ‫؍‬ .12). Multipleorgan-dysfunction-free days (median 6 vs 20.5 d, P ‫؍‬ .02), respiratory-failure-free days (median 7.5 vs 14.5 d, P ‫؍‬ .03), and hemodynamic-failure-free days (median 16 vs 22 d, P ‫؍‬ .04) at 28 days were significantly lower in subjects with compliance-guided setting of PEEP. CONCLUSIONS: In ARDS subjects, protective mechanical ventilation with PEEP application according to the highest compliance was associated with less organ dysfunction and a strong nonsignificant trend toward lower mortality. ClinicalTrials.gov Number NCT01119872.

Elderly ICU survivors experienced significant deterioration in functional status, and although they recovered modestly during the following year, they never regained their baseline status. Good recovery was associated with short ICU stay and better baseline functional status.

Background. There are few data regarding the process of deciding which elderly patients are refused to ICU admission, their characteristics, and outcome. Methods. Prospective longitudinal observational cohort study. We included all consecutive patients older than 75 years, who were evaluated for admission to but were refused to treatment in ICU, during 18 months, with 12-month followup. We collected demographic data, ICU admission/refusal reasons, previous functional and cognitive status, comorbidity, severity of illness, and hospital and 12-month mortality. Results. 338 elderly patients were evaluated for ICU admission and 88 were refused to ICU (26%). Patients refused because they were “too ill to benefit” had more comorbidity and worse functional and mental situation than those admitted to ICU; there were no differences in illness severity. Hospital mortality rate of the whole study cohort was 36.3%, higher in patients “too ill to benefit” (55.6% versus 35.8%, P < 0.01), which also have higher 1-year mortality (73.7% versus 42.5%, P < 0.01). High comorbidity, low functional status, unavailable ICU beds, and age were associated with refusal decision on multivariate analysis. Conclusions. Prior functional status and comorbidity, not only the age or severity of illness, can help us more to make the right decision of admitting or refusing to ICU patients older than 75 years.

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