The acute respiratory distress syndrome (ARDS), the most severe form of acute lung injury, is a deadly condition characterized by infiltrates on chest radiography and severe hypoxemia not secondary to left heart failure. The syndrome affects approximately 200 000 adults in the United States annually and has a mortality of 35% to 45%.1 Ironically, mechanical ventilation—a therapy that is initially lifesaving—has contributed to the subsequent high mortality. In clinicians' previous zeal to maintain relatively normal blood gas values, they ventilated patients using relatively large tidal volumes. This approach changed with greater insight into the pathophysiology of ARDS, better understanding of the importance of ventilator-induced lung injury,2 and a large-scale clinical trial demonstrating that a ventilatory strategy using smaller tidal volumes decreased mortality from 40% to 31%.3 However, mortality in patients with ARDS remains high, and in some patients the current lung-protective strategy is not lung-protective enough. This has led to ongoing research into better methods of applying mechanical ventilation.
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