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October 24/31, 2012

Low Tidal Volumes for All?

Author Affiliations

Author Affiliations: Interdepartmental Division of Critical Care Medicine, Departments of Medicine and Physiology, University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.

JAMA. 2012;308(16):1689-1690. doi:10.1001/jama.2012.14509

Clinicians are continually striving to improve the quality of care in medicine. In the intensive care unit (ICU) environment, the focus on quality has been on avoidance of iatrogenic complications. Mechanical ventilation provides a specific example; treatment goals have changed remarkably in the last 20 years—from maintaining “normal” blood gas values to supporting acceptable gas exchange while avoiding or minimizing ventilator-induced lung injury.1 Previously, ventilator-induced lung injury was only recognized when overt barotrauma such as pneumothorax occurred. Today, however, a more insidious form of ventilator-induced lung injury is recognized, one that arises through cyclic alveolar over-distension (volutrauma) and other mechanisms and can produce local and systemic inflammatory reactions leading to multiorgan failure and death.2 The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network clinical trial demonstrated that the use of low tidal volumes in patients with established acute respiratory distress syndrome (ARDS) results in a considerable reduction in mortality.3 Until now, the focus of lung-protective ventilation has remained on treatment of ARDS.