To the Editor The ART investigators performed a multicenter randomized clinical trial comparing a high-PEEP strategy using lung recruitment with titrated PEEP vs a low-PEEP strategy in patients with ARDS.1 The trial, however, still leaves unanswered questions.
Hyperoxia-induced lung injury causes an ARDS-type picture with edema, fibrosis, and vascular remodeling,2 although the mechanisms by which reactive oxygen species promote cellular apoptosis and necrosis are not yet fully understood. All patients with ARDS are exposed to prolonged high fractional inspired concentrations of oxygen (Fio2) to manage hypoxemia. In the ART trial, participants were subjected to an additional Fio2 of 1.0 for 30 minutes prior to alveolar stretch, the necessity of which is unclear, because this is neither a required step for establishing the presence of ARDS nor grading its severity.3
Morris IS, Lane AS, Seppelt I. Lung Recruitment and Positive End-Expiratory Pressure Titration in Patients With Acute Respiratory Distress Syndrome. JAMA. 2018;319(9):933–934. doi:10.1001/jama.2017.21844
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