Nevertheless, one year after publication of the ARDSnet trial, Rubenfeld et al noted that lung-protective ventilation strategies were applied in less than 5% of patients with ARDS or ALI at a single ARDSnet center. Rubenfeld et al found that common barriers to the initiation of low tidal volume ventilation include unwillingness to relinquish control of the ventilator, failure to recognize patients as having ALI/ARDS, and perceived contraindications to low tidal volume ventilation. Significant barriers to the continuation of low tidal volume ventilation include concerns regarding patient discomfort and tachypnea or hypercapnia and acidosis.