Should the ART trial change our practice?

Should the ART trial change our practice?

“…A total of 1,010 patients were enrolled in 120 sites. Contrary to most expectations, the results showed that open lung strategy increased 28-day mortality (6). It also resulted in a higher risk of barotrauma in 7 days and hypotension or need to start or increase vasopressors in 1 hour.…”

“…Multiprofessional ICU teams of all sites were trained in loco before enrolling the first patient (except for Malaysia trained with web conference). All sites received several copies of didactic bedside manuals of operations (available with the main paper supplement) (6). We held annual investigators meetings and formal teleconferences 3 times per year.…”

“…Dr. Villar and colleagues wrote an editorial raising several concerns regarding the ART and cautioning against application of its results to clinical practice (6). First is the 28-day mortality observed in the control group of the trial (49.3%), higher than most recent randomized trials.…”

Optimal Ventilator Strategies in Acute Respiratory Distress Syndrome

“…69 A high proportion of patient-ventilator asynchrony in the experimental arm raised further concerns for significant VILI during controlled ventilation. 70,71 Some of these issues may explain this trial's disappointing result. Of note, a recent pilot RCT which also involved recruitment maneuvers and a decremental PEEP trial identifying the PEEP level associated with the maximum dynamic compliance demonstrated that an open lung approach improved oxygenation and respiratory system mechanics without detrimental effects on 60-day mortality, ventilator-free days, or barotrauma 72 and set the stage for a larger trial.…”

“…70 One major concern was that the duration and amplitude of the lung recruitment maneuver in the experimental arm were excessive, increasing the risk of respiratory acidosis and barotrauma. 70 Peak recruitment pressures of 60 cm H 2 O and a recruitment time process of 24 minutes without ensuring adequate volume resuscitation might have explained in part the three cardiac arrests and seven pneumothoraces documented during recruitment. 69 A high proportion of patient-ventilator asynchrony in the experimental arm raised further concerns for significant VILI during controlled ventilation.…”