Lung protective ventilation strategy for the acute respiratory distress syndrome

  • Review
  • Intervention




Patients with acute respiratory distress syndrome and acute lung injury require mechanical ventilatory support. Acute respiratory distress syndrome and acute lung injury are further complicated by ventilator-induced lung injury. Lung protective ventilation strategies may lead to improved survival. This systematic review is an update of a Cochrane review originally published in 2003 and updated in 2007.


To assess the effects of ventilation with lower tidal volume on morbidity and mortality in patients aged 16 years or older affected by acute respiratory distress syndrome and acute lung injury. A secondary objective was to determine whether the comparison between low and conventional tidal volume was different if a plateau airway pressure of greater than 30 to 35 cm H20 was used.

Search methods

In our previous 2007 updated review, we searched databases from inception until 2006. In this third updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL and the Web of Science from 2006 to September 2012. We also updated our search of databases of ongoing research and of reference lists from 2006 to September 2012.

Selection criteria

We included randomized controlled trials comparing ventilation using either a lower tidal volume (Vt) or low airway driving pressure (plateau pressure 30 cm H2O or less), resulting in a tidal volume of 7 ml/kg or less, versus ventilation that used Vt in the range of 10 to 15 ml/kg in adults (16 years old or older) with acute respiratory distress syndrome and acute lung injury.

Data collection and analysis

We independently assessed trial quality and extracted data. Wherever appropriate, results were pooled. We applied fixed-effect and random-effects models.

Main results

We did not find any new study which were eligible for inclusion in this update. The total number of studies remained unchanged, six trials involving 1297 patients. Five trials had a low risk of bias. One trial had an unclear risk of bias. Mortality at day 28 was significantly reduced by lung-protective ventilation with a relative risk (RR) of 0.74 (95% confidence interval (CI) 0.61 to 0.88); hospital mortality was reduced with a RR of 0.80 (95% CI 0.69 to 0.92). Overall mortality was not significantly different if a plateau pressure less than or equal to 31 cm H2O in the control group was used (RR 1.13, 95% CI 0.88 to 1.45). There was insufficient evidence for morbidity and long-term outcomes.

Authors' conclusions

Clinical heterogeneity, such as different lengths of follow up and higher plateau pressure in control arms in two trials, makes the interpretation of the combined results difficult. Mortality was significantly reduced at day 28 and at the end of the hospital stay. The effects on long-term mortality are unknown, although the possibility of a clinically relevant benefit cannot be excluded. Ventilation with lower tidal volumes is becoming a routine strategy of treatment of acute respiratory distress syndrome and acute lung injury, stopping investigators from carrying out additional trials.










我们纳入了干预使用低潮气量(Vt)或低气道驱动压力(平台压力30cm水柱或更低)使潮气量为7ml / kg或更低,对照使用Vt在10至15 ml / kg范围内的通气治疗成人(16岁或以上)急性呼吸窘迫综合征和急性肺损伤的随机对照试验。




本次更新我们没有找到任何符合纳入条件的新研究。研究总数保持不变,6项试验涉及1297例。5项试验偏倚风险偏低。一项试验有不明确的偏倚风险。肺保护通气在第28天的死亡率明显降低,相对风险(RR)为0.74(95%置信区间(CI)0.61〜0.88);住院死亡率降低,RR为0.80(95%CI为0.69至0.92)。如果对照组使用的平均血压小于或等于31厘米水柱,总死亡率没有显着差异(RR=1.13, 95%CI=0.88〜1.45)。发病率和长期结局方面没有足够证据。





Plain language summary

A gentler form of mechanical breathing for people affected by severe lung failure

Critically ill people affected by severe, acute respiratory failure need air to be pumped into their lungs (mechanical ventilation) to survive. Mechanical support buys time for the lungs to heal. Nevertheless, 35% to 65% still die. Several studies have suggested that mechanical breathing can also cause lung damage and bleeding. A new lung protective way of mechanical ventilation was tested in large studies. In this third update of the Cochrane review we searched the databases until September 2012 but we did not find any new study which was eligible for inclusion. The total number of studies remained unchanged, six trials involving 1297 people. This systematic review shows that a gentler form of mechanical breathing (so-called protective ventilation) can decrease deaths in the short term, by 26% on average, but the effects in the long term are uncertain or unknown.