Sistema FMUSP-HC: Faculdade de Medicina da Universidade de São Paulo (FMUSP) e Hospital das Clínicas da FMUSPCAVALCANTI, Alexandre BiasiSUZUMURA, Erica AranhaLARANJEIRA, Ligia NasiPAISANI, Denise de MoraesDAMIANI, Lucas PetriGUIMARAES, Helio PennaROMANO, Edson RenatoREGENGA, Marisa de MoraesTANIGUCHI, Luzia Noriko TakahashiTEIXEIRA, CassianoOLIVEIRA, Roselaine Pinheiro deMACHADO, Flavia RibeiroDIAZ-QUIJANO, Fredi AlexanderALENCAR FILHO, Meton Soares deMAIA, Israel SilvaCASER, Eliana BernardeteOLIVEIRA FILHO, Wilson deBORGES, Marcos de CarvalhoMARTINS, Priscilla de AquinoMATSUI, MirnaOSPINA-TASCON, Gustavo AdolfoGIANCURSI, Thiago SimoesGIRALDO-RARNIREZ, Nelson DarioVIEIRA, Silvia Regina RiosASSEF, Maria da Graca Pasquotto de LimaHASAN, Mohd ShahnazSZCZELDIK, WojciechRIOS, FernandoAMATO, Marcelo Britto PassosBERWANGER, OtavioCARVALHO, Carlos Roberto Ribeiro de2017-12-122017-12-122017JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, v.318, n.14, p.1335-1345, 20170098-7484https://observatorio.fm.usp.br/handle/OPI/24210IMPORTANCE The effects of recruitment maneuvers and positive end-expiratory pressure (PEEP) titration on clinical outcomes in patients with acute respiratory distress syndrome (ARDS) remain uncertain. OBJECTIVE To determine if lung recruitment associated with PEEP titration according to the best respiratory-system compliance decreases 28-day mortality of patients with moderate to severe ARDS compared with a conventional low-PEEP strategy. DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized trial conducted at 120 intensive care units (ICUs) from 9 countries from November 17, 2011, through April 25, 2017, enrolling adults with moderate to severe ARDS. INTERVENTIONS An experimental strategy with a lung recruitment maneuver and PEEP titration according to the best respiratory-system compliance (n = 501; experimental group) or a control strategy of low PEEP (n = 509). All patients received volume-assist control mode until weaning. MAIN OUTCOMES AND MEASURES The primary outcomewas all-cause mortality until 28 days. Secondary outcomes were length of ICU and hospital stay; ventilator-free days through day 28; pneumothorax requiring drainage within 7 days; barotrauma within 7 days; and ICU, in-hospital, and 6-month mortality. RESULTS A total of 1010 patients (37.5% female; mean [SD] age, 50.9 [17.4] years) were enrolled and followed up. At 28 days, 277 of 501 patients (55.3%) in the experimental group and 251 of 509 patients (49.3%) in the control group had died (hazard ratio [HR], 1.20; 95% CI, 1.01 to 1.42; P =.041). Compared with the control group, the experimental group strategy increased 6-month mortality (65.3% vs 59.9%; HR, 1.18; 95% CI, 1.01 to 1.38; P =.04), decreased the number of mean ventilator-free days (5.3 vs 6.4; difference, -1.1; 95% CI, -2.1 to -0.1; P =.03), increased the risk of pneumothorax requiring drainage (3.2% vs 1.2%; difference, 2.0%; 95% CI, 0.0% to 4.0%; P =.03), and the risk of barotrauma (5.6% vs 1.6%; difference, 4.0%; 95% CI, 1.5% to 6.5%; P =.001). There were no significant differences in the length of ICU stay, length of hospital stay, ICU mortality, and in-hospital mortality. CONCLUSIONS AND RELEVANCE In patients with moderate to severe ARDS, a strategy with lung recruitment and titrated PEEP compared with low PEEP increased 28-day all-cause mortality. These findings do not support the routine use of lung recruitment maneuver and PEEP titration in these patients.engrestrictedAccessventilation strategydriving pressuretidal volumesards patientsinjurymaneuverssubphenotypesmetaanalysisoutcomesarticleCopyright AMER MEDICAL ASSOC10.1001/jama.2017.14171Medicine, General & Internal1538-3598