Brower Roy G, Matthay Michael A, Morris Alan, Schoenfeld David, Thompson B Taylor, Wheeler Arthur
N Engl J Med. 2000 May 4;342(18):1301-8. doi: 10.1056/NEJM200005043421801.
Traditional approaches to mechanical ventilation use tidal volumes of 10 to 15 ml per kilogram of body weight and may cause stretch-induced lung injury in patients with acute lung injury and the acute respiratory distress syndrome. We therefore conducted a trial to determine whether ventilation with lower tidal volumes would improve the clinical outcomes in these patients.
Patients with acute lung injury and the acute respiratory distress syndrome were enrolled in a multicenter, randomized trial. The trial compared traditional ventilation treatment, which involved an initial tidal volume of 12 ml per kilogram of predicted body weight and an airway pressure measured after a 0.5-second pause at the end of inspiration (plateau pressure) of 50 cm of water or less, with ventilation with a lower tidal volume, which involved an initial tidal volume of 6 ml per kilogram of predicted body weight and a plateau pressure of 30 cm of water or less. The primary outcomes were death before a patient was discharged home and was breathing without assistance and the number of days without ventilator use from day 1 to day 28.
The trial was stopped after the enrollment of 861 patients because mortality was lower in the group treated with lower tidal volumes than in the group treated with traditional tidal volumes (31.0 percent vs. 39.8 percent, P=0.007), and the number of days without ventilator use during the first 28 days after randomization was greater in this group (mean [+/-SD], 12+/-11 vs. 10+/-11; P=0.007). The mean tidal volumes on days 1 to 3 were 6.2+/-0.8 and 11.8+/-0.8 ml per kilogram of predicted body weight (P<0.001), respectively, and the mean plateau pressures were 25+/-6 and 33+/-8 cm of water (P<0.001), respectively.
In patients with acute lung injury and the acute respiratory distress syndrome, mechanical ventilation with a lower tidal volume than is traditionally used results in decreased mortality and increases the number of days without ventilator use.
传统的机械通气方法采用每公斤体重10至15毫升的潮气量，这可能会在急性肺损伤和急性呼吸窘迫综合征患者中导致拉伸性肺损伤。因此，我们进行了一项试验，以确定采用较低潮气量通气是否会改善这些患者的临床结局。
急性肺损伤和急性呼吸窘迫综合征患者被纳入一项多中心随机试验。该试验将传统通气治疗（初始潮气量为每公斤预测体重12毫升，吸气末0.5秒停顿后测量的气道压力（平台压）为50厘米水柱或更低）与较低潮气量通气（初始潮气量为每公斤预测体重6毫升，平台压为30厘米水柱或更低）进行了比较。主要结局为患者出院回家且无需辅助呼吸前的死亡情况以及从第1天到第28天无呼吸机使用的天数。
在纳入861例患者后试验停止，因为较低潮气量治疗组的死亡率低于传统潮气量治疗组（31.0%对39.8%，P = 0.007），且该组在随机分组后的前28天内无呼吸机使用的天数更多（均值[±标准差]，12 ± 11对10 ± 11；P = 0.007）。第1至3天的平均潮气量分别为每公斤预测体重6.2 ± 0.8和11.8 ± 0.8毫升（P < 0.001），平均平台压分别为25 ± 6和33 ± 8厘米水柱（P < 0.001）。
在急性肺损伤和急性呼吸窘迫综合征患者中，采用低于传统用量的较低潮气量进行机械通气可降低死亡率，并增加无呼吸机使用的天数。
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