RT Book, Section A1 Adrish, Muhammad A1 Soto, Graciela J. A2 Oropello, John M. A2 Pastores, Stephen M. A2 Kvetan, Vladimir SR Print(0) ID 1136418213 T1 Controversies: Ventilator Management in ARDS: One Size Fits All? T2 Critical Care YR 1 FD 1 PB McGraw-Hill Education PP New York, NY SN 9780071820813 LK accessanesthesiology.mhmedical.com/content.aspx?aid=1136418213 RD 2024/03/28 AB KEY POINTSThe pathophysiologic changes in the acute respiratory distress syndrome (ARDS) produce low-compliant lungs containing areas of atelectasis and reduced lung volumes.Positive pressure ventilation in this heterogenous syndrome can lead to overdistension of normally aerated lung regions and stress injury in atelectatic alveoli due to cyclic recruitment and derecruitment.Use of low-tidal-volume ventilation as lung-protection strategy has been studied since 1960s. Despite suggested benefits, concerns regarding additional metabolic abnormalities and hypoxemia in critically ill patients have existed.Results of the landmark ARDS in a large multicentre randomized trial found that the use of low tidal volume (6 mL/kg ideal body weight [IBW]) rather than “standard” tidal volume (12 mL/kg IBW) significantly reduced mortality. Although the trial was criticized for using excessively large tidal volumes in controls, the trial investigators subsequently published trial data detailing the clinical benefits of tidal volume and plateau pressure reduction across the range of disease severity and plateau pressures.Recent data suggest that many mechanically ventilated patients with ARDS have stress index that indicates alveolar hyperventilation while receiving positive end-expiratory pressure (PEEP) according to the ARDS Network recommendation, advocating even lower tidal volumes.Use of adjunct therapies such as extracorporeal membrane oxygenation may be useful in select patients where lowering tidal volume can lead to serious metabolic abnormalities.