6. In perhaps the largest study of sustained inflations in the protective ventilation era, Meade, et al14 studied 983 adults with ARDS utilizing lung protective strategies (tidal volumes 6 mL/kg) in both groups. The experimental group utilized SI recruitment maneuvers (40 cm H2O for 40 seconds), higher levels of PEEP (14.6±3.4 in the so-called 'lung open ventilation' group versus 9.8±2.7 in the control group), and higher plateau pressures (30.2±6.3 versus 24.9±5.1 cm H2O) than the control group, which did not utilize recruitment maneuvers. While there was no difference in all-cause mortality, the experimental group had lower rates of refractory hypoxemia (4.6% vs 10.2%; RR, 0.54), death with refractory hypoxemia (4.2% vs 8.9%; RR, 0.56), and less frequent use of escalated therapies (defined as high frequency ventilation, inhaled nitric oxide, jet ventilation, or extra-corporeal support) (5.1% vs 9.3%; RR, 0.6). This lends credence to the notion that effective recruitment of children early in acute lung injury may avert escalation of therapy and decrease the mortality due to severe hypoxia.