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Ventilation with lower tidal volumes for critically ill patients without the acute respiratory distress syndrome: a systematic translational review and meta-analysis

Serpa Neto, Arya,b,c; Nagtzaam, Liselottec; Schultz, Marcus J.c,d

Current Opinion in Critical Care: February 2014 - Volume 20 - Issue 1 - p 25–32
doi: 10.1097/MCC.0000000000000044
RESPIRATORY SYSTEM: Edited by Peolo Pelosi

Purpose of review There is convincing evidence for benefit from lung-protective mechanical ventilation with lower tidal volumes in patients with the acute respiratory distress syndrome (ARDS). It is uncertain whether this strategy benefits critically ill patients without ARDS as well. This manuscript systematically reviews recent preclinical studies of ventilation in animals with uninjured lungs, and clinical trials of ventilation in ICU patients without ARDS on the association between tidal volume size and pulmonary complications and outcome.

Recent findings Successive preclinical studies almost without exception show that ventilation with lower tidal volumes reduces the injurious effects of ventilation in animals with uninjured lungs. This finding is in line with results from recent trials in ICU patients without ARDS, demonstrating that ventilation with lower tidal volumes has a strong potential to prevent development of pulmonary complications and maybe even to improve survival. However, evidence mostly comes from nonrandomized clinical trials, and concerns are expressed regarding unselected use of lower tidal volumes in the ICU, that is, in all ventilated critically ill patients, since this strategy could also increase needs for sedation and/or neuromuscular blockade, and maybe even cause respiratory muscle fatigue. These all then could in fact worsen outcome, possibly counteracting the beneficial effects of ventilation with lower tidal volumes.

Summary Ventilation with lower tidal volumes protects against pulmonary complications, but well-powered randomized controlled trials are urgently needed to determine whether this ventilation strategy truly benefits all ventilated ICU patients without ARDS.

aMedical Intensive Care Unit, ABC Medical School (FMABC), Santo André

bDepartment of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil

cDepartment of Intensive Care

dLaboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands

Correspondence to Ary Serpa Neto, MD, MSc, Av. Lauro Gomes, 2000, Santo André, Brazil. Tel: +55(11) 4993 5400; fax: +55(11) 4993 5400; e-mail:

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins