human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective : The open lung approach is a mechanical ventilation strategy involving lung recruitment and a decremental positive end-expiratory pressure trial . We compared the Acute Respiratory Distress Syndrome network protocol using low levels of positive end-expiratory pressure with open lung approach result ing in moderate to high levels of positive end-expiratory pressure for the management of established moderate/severe acute respiratory distress syndrome . Design : A prospect i ve , multicenter , pilot , r and omized controlled trial . Setting : A network of 20 multidisciplinary ICUs . Patients : Patients meeting the American-European Consensus Conference definition for acute respiratory distress syndrome were considered for the study . Interventions : At 12 - 36 hours after acute respiratory distress syndrome onset , patients were  assessed under st and ardized ventilator setting s ( FIO2≥0.5 , positive end-expiratory pressure ≥10 cm H2O ) . If Pao2/FIO2 ratio remained less than or equal to 200 mm Hg , patients were r and omized to open lung approach or Acute Respiratory Distress Syndrome network protocol . All patients were ventilated with a tidal volume of 4 to 8 ml/kg predicted body weight . Measurements and Main Results : From 1,874 screened patients with acute respiratory distress syndrome , 200 were r and omized : 99 to open lung approach and 101 to Acute Respiratory Distress Syndrome network protocol . Main outcome measures were 60-day and ICU mortalities , and ventilator-free days . Mortality at day-60 ( 29 % open lung approach vs. 33 % Acute Respiratory Distress Syndrome Network protocol , p = 0.18 , log rank test ) , ICU mortality ( 25 % open lung approach vs. 30 % Acute Respiratory Distress Syndrome network protocol , p = 0.53 Fisher ’s exact test ) , and ventilator-free days ( 8 [ 0 - 20 ] open lung approach vs. 7 [ 0 - 20 ] d Acute Respiratory Distress Syndrome network protocol , p = 0.53 Wilcoxon rank test ) were not significantly different . Airway driving pressure ( plateau pressure - positive end-expiratory pressure ) and PaO2/FIO2 improved significantly at 24 , 48 and 72 hours in patients in open lung approach compared with patients in Acute Respiratory Distress Syndrome network protocol . Barotrauma rate was similar in both groups . Conclusions : In patients with established acute respiratory distress syndrome , open lung approach improved oxygenation and driving pressure , without detrimental effects on mortality , ventilator-free days , or barotrauma . This pilot study supports the need for a large , multicenter trial using recruitment maneuvers and a decremental positive end-expiratory pressure trial in persistent acute respiratory distress syndrome Importance The effects of recruitment maneuvers and positive end-expiratory pressure ( PEEP ) titration on clinical outcomes in patients with acute respiratory distress syndrome ( ARDS ) remain uncertain . Objective To determine if lung recruitment associated with PEEP titration according to the best respiratory-system compliance decreases 28-day mortality of patients with moderate to severe ARDS compared with a conventional low-PEEP strategy . Design , Setting , and Participants Multicenter , r and omized trial conducted at 120 intensive care units ( ICUs ) from 9 countries from November 17 , 2011 , through April 25 , 2017 , enrolling adults with moderate to severe ARDS . Interventions An experimental strategy with a lung recruitment maneuver and PEEP titration according to the best respiratory – system compliance ( n = 501 ; experimental group ) or a control strategy of low PEEP ( n = 509 ) . All patients received volume-assist control mode until weaning . Main Outcomes and Measures The primary outcome was all-cause mortality until 28 days . Secondary outcomes were length of ICU and hospital stay ; ventilator-free days through day 28 ; pneumothorax requiring drainage within 7 days ; barotrauma within 7 days ; and ICU , in-hospital , and 6-month mortality . Results A total of 1010 patients ( 37.5 % female ; mean [ SD ] age , 50.9 [ 17.4 ] years ) were enrolled and followed up . At 28 days , 277 of 501 patients ( 55.3 % ) in the experimental group and 251 of 509 patients ( 49.3 % ) in the control group had died ( hazard ratio [ HR ] , 1.20 ; 95 % CI , 1.01 to 1.42 ; P = .041 ) . Compared with the control group , the experimental group strategy increased 6-month mortality ( 65.3 % vs 59.9 % ; HR , 1.18 ; 95 % CI , 1.01 to 1.38 ; P = .04 ) , decreased the number of mean ventilator-free days ( 5.3 vs 6.4 ; difference , −1.1 ; 95 % CI , −2.1 to −0.1 ; P = .03 ) , increased the risk of pneumothorax requiring drainage ( 3.2 % vs 1.2 % ; difference , 2.0 % ; 95 % CI , 0.0 % to 4.0 % ; P = .03 ) , and the risk of barotrauma ( 5.6 % vs 1.6 % ; difference , 4.0 % ; 95 % CI , 1.5 % to 6.5 % ; P = .001 ) . There were no significant differences in the length of ICU stay , length of hospital stay , ICU mortality , and in-hospital mortality . Conclusions and Relevance In patients with moderate to severe ARDS , a strategy with lung recruitment and titrated PEEP compared with low PEEP increased 28-day all-cause mortality . These findings do not support the routine use of lung recruitment maneuver and PEEP titration in these patients . Trial Registration clinical trials.gov Identifier : Introduction Alveolar derecruitment may occur during low tidal volume ventilation and may be prevented by recruitment maneuvers ( RMs ) . The aim of this study was to compare two RMs in acute respiratory distress syndrome ( ARDS ) patients . Methods Nineteen patients with ARDS and protective ventilation were included in a r and omized crossover study . Both RMs were applied in each patient , beginning with either continuous positive airway pressure ( CPAP ) with 40 cm H2O for 40 seconds or extended sigh ( eSigh ) consisting of a positive end-expiratory pressure maintained at 10 cm H2O above the lower inflection point of the pressure-volume curve for 15 minutes . Recruited volume , arterial partial pressure of oxygen/fraction of inspired oxygen ( PaO2/FiO2 ) , and hemodynamic parameters were recorded before ( baseline ) and 5 and 60 minutes after RM . All patients had a lung computed tomography ( CT ) scan before study inclusion . Results Before RM , PaO2/FiO2 was 151 ± 61 mm Hg . Both RMs increased oxygenation , but the increase in PaO2/FiO2 was significantly higher with eSigh than CPAP at 5 minutes ( 73 % ± 25 % versus 44 % ± 28 % ; P < 0.001 ) and 60 minutes ( 68 % ± 23 % versus 35 % ± 22 % ; P < 0.001 ) . Only eSigh significantly increased recruited volume at 5 and 60 minutes ( 21 % ± 22 % and 21 % ± 25 % ; P = 0.0003 and P = 0.001 , respectively ) . The only difference between responders and non-responders was CT lung morphology . Eleven patients were considered as recruiters with eSigh ( 10 with diffuse loss of aeration ) and 6 with CPAP ( 5 with diffuse loss of aeration ) . During CPAP , 2 patients needed interruption of RM due to a drop in systolic arterial pressure . Conclusion Both RMs effectively increase oxygenation , but CPAP failed to increase recruited volume . When the lung is recruited with an eSigh adapted for each patient , alveolar recruitment and oxygenation are superior to those observed with CPAP Introduction In acute respiratory distress syndrome ( ARDS ) , adequate positive end-expiratory pressure ( PEEP ) may decrease ventilator-induced lung injury by minimising overinflation and cyclic recruitment-derecruitment of the lung . We evaluated whether setting the PEEP using decremental PEEP titration after an alveolar recruitment manoeuvre ( ARM ) affects the clinical outcome in patients with ARDS . Methods Fifty-seven patients with early ARDS were r and omly assigned to a group given decremental PEEP titration following ARM or a table-based PEEP ( control ) group . PEEP  and  inspired fraction of oxygen ( FiO2 )  in the control group were set according to the table-based combinations of FiO2 and PEEP of the ARDS network , by which we aim ed to achieve a PEEP level compatible with an oxygenation target . In the decremental PEEP titration group , the oxygen saturation and static compliance were monitored as the patients performed the ARM along with the extended sigh method , which is design ed to gradually apply and withdraw a high distending pressure over a prolonged period , and the decremental titration of PEEP . Results The baseline characteristics did not differ significantly between the control and decremental PEEP titration groups . Initial oxygenation improved more in the decremental PEEP titration group than in the control group . However , dynamic compliance , tidal volume and PEEP were similar in the two groups during the first week . The duration of use of paralysing or sedative agents , mechanical ventilation , stay in the intensive care unit and mortality at 28 days did not differ significantly between the decremental PEEP titration and control groups . Conclusions The daily decremental PEEP titration after ARM showed only initial oxygenation improvement compared with the table-based PEEP method . Respiratory mechanics and patient outcomes did not differ between the decremental PEEP titration and control groups . Trial registration Clinical Trials.gov identifier : IS RCT N79027921 Introduction Tidal volume and plateau pressure minimisation are the st and ard components of a protective lung ventilation strategy for patients with acute respiratory distress syndrome ( ARDS ) . Open lung strategies , including higher positive end-expiratory pressure ( PEEP ) and recruitment manoeuvres to date have not proven efficacious . This study examines the effectiveness and safety of a novel open lung strategy , which includes permissive hypercapnia , staircase recruitment manoeuvres ( SRM ) and low airway pressure with PEEP titration . Method Twenty ARDS patients were r and omised to treatment or ARDSnet control ventilation strategies . The treatment group received SRM with decremental PEEP titration and targeted plateau pressure < 30 cm H2O . Gas exchange and lung compliance were measured daily for 7 days and plasma cytokines in the first 24 hours and on days 1 , 3 , 5 and 7 ( mean ± SE ) . Duration of ventilation , ICU stay and hospital stay ( median and interquartile range ) and hospital survival were determined . Results There were significant overall differences between groups when considering plasma IL-8 and TNF-α . For plasma IL-8 , the control group was 41 % higher than the treatment group over the seven-day period ( ratio 1.41 ( 1.11 to 1.79 ) , P = 0.01 ) , while for TNF-α the control group was 20 % higher over the seven-day period ( ratio 1.20 ( 1.01 to 1.42 ) P = 0.05 ) . PaO2/FIO2 ( 204 ± 9 versus 165 ± 9 mmHg , P = 0.005 ) and static lung compliance ( 49.1 ± 2.9 versus 33.7 ± 2.7 mls/cm H2O , P < 0.001 ) were higher in the treatment group than the control group over seven days . There was no difference in duration of ventilation ( 180 ( 87 to 298 ) versus 341 ( 131 to 351 ) hrs , P = 0.13 ) , duration of ICU stay ( 9.9 ( 5.6 to 14.8 ) versus 16.0 ( 8.1 to 19.3 ) days , P = 0.19 ) and duration of hospital stay ( 17.9 ( 13.7 to 34.5 ) versus 24.7 ( 20.5 to 39.8 ) days , P = 0.16 ) between the treatment and control groups . Conclusions This open lung strategy was associated with greater amelioration in some systemic cytokines , improved oxygenation and lung compliance over seven days . A larger trial powered to examine clinical ly-meaningful outcomes is warranted . Trial registration BACKGROUND In the acute respiratory distress syndrome ( ARDS ) , positive end-expiratory pressure ( PEEP ) may decrease ventilator-induced lung injury by keeping lung regions open that otherwise would be collapsed . Since the effects of PEEP probably depend on the recruitability of lung tissue , we conducted a study to examine the relationship between the percentage of potentially recruitable lung , as indicated by computed tomography ( CT ) , and the clinical and physiological effects of PEEP . METHODS Sixty-eight patients with acute lung injury or ARDS underwent whole-lung CT 
    Output:
    
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***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective : The open lung approach is a mechanical ventilation strategy involving lung recruitment and a decremental positive end-expiratory pressure trial . We compared the Acute Respiratory Distress Syndrome network protocol using low levels of positive end-expiratory pressure with open lung approach result ing in moderate to high levels of positive end-expiratory pressure for the management of established moderate/severe acute respiratory distress syndrome . Design : A prospect i ve , multicenter , pilot , r and omized controlled trial . Setting : A network of 20 multidisciplinary ICUs . Patients : Patients meeting the American-European Consensus Conference definition for acute respiratory distress syndrome were considered for the study . Interventions : At 12 - 36 hours after acute respiratory distress syndrome onset , patients were  assessed under st and ardized ventilator setting s ( FIO2≥0.5 , positive end-expiratory pressure ≥10 cm H2O ) . If Pao2/FIO2 ratio remained less than or equal to 200 mm Hg , patients were r and omized to open lung approach or Acute Respiratory Distress Syndrome network protocol . All patients were ventilated with a tidal volume of 4 to 8 ml/kg predicted body weight . Measurements and Main Results : From 1,874 screened patients with acute respiratory distress syndrome , 200 were r and omized : 99 to open lung approach and 101 to Acute Respiratory Distress Syndrome network protocol . Main outcome measures were 60-day and ICU mortalities , and ventilator-free days . Mortality at day-60 ( 29 % open lung approach vs. 33 % Acute Respiratory Distress Syndrome Network protocol , p = 0.18 , log rank test ) , ICU mortality ( 25 % open lung approach vs. 30 % Acute Respiratory Distress Syndrome network protocol , p = 0.53 Fisher ’s exact test ) , and ventilator-free days ( 8 [ 0 - 20 ] open lung approach vs. 7 [ 0 - 20 ] d Acute Respiratory Distress Syndrome network protocol , p = 0.53 Wilcoxon rank test ) were not significantly different . Airway driving pressure ( plateau pressure - positive end-expiratory pressure ) and PaO2/FIO2 improved significantly at 24 , 48 and 72 hours in patients in open lung approach compared with patients in Acute Respiratory Distress Syndrome network protocol . Barotrauma rate was similar in both groups . Conclusions : In patients with established acute respiratory distress syndrome , open lung approach improved oxygenation and driving pressure , without detrimental effects on mortality , ventilator-free days , or barotrauma . This pilot study supports the need for a large , multicenter trial using recruitment maneuvers and a decremental positive end-expiratory pressure trial in persistent acute respiratory distress syndrome Importance The effects of recruitment maneuvers and positive end-expiratory pressure ( PEEP ) titration on clinical outcomes in patients with acute respiratory distress syndrome ( ARDS ) remain uncertain . Objective To determine if lung recruitment associated with PEEP titration according to the best respiratory-system compliance decreases 28-day mortality of patients with moderate to severe ARDS compared with a conventional low-PEEP strategy . Design , Setting , and Participants Multicenter , r and omized trial conducted at 120 intensive care units ( ICUs ) from 9 countries from November 17 , 2011 , through April 25 , 2017 , enrolling adults with moderate to severe ARDS . Interventions An experimental strategy with a lung recruitment maneuver and PEEP titration according to the best respiratory – system compliance ( n = 501 ; experimental group ) or a control strategy of low PEEP ( n = 509 ) . All patients received volume-assist control mode until weaning . Main Outcomes and Measures The primary outcome was all-cause mortality until 28 days . Secondary outcomes were length of ICU and hospital stay ; ventilator-free days through day 28 ; pneumothorax requiring drainage within 7 days ; barotrauma within 7 days ; and ICU , in-hospital , and 6-month mortality . Results A total of 1010 patients ( 37.5 % female ; mean [ SD ] age , 50.9 [ 17.4 ] years ) were enrolled and followed up . At 28 days , 277 of 501 patients ( 55.3 % ) in the experimental group and 251 of 509 patients ( 49.3 % ) in the control group had died ( hazard ratio [ HR ] , 1.20 ; 95 % CI , 1.01 to 1.42 ; P = .041 ) . Compared with the control group , the experimental group strategy increased 6-month mortality ( 65.3 % vs 59.9 % ; HR , 1.18 ; 95 % CI , 1.01 to 1.38 ; P = .04 ) , decreased the number of mean ventilator-free days ( 5.3 vs 6.4 ; difference , −1.1 ; 95 % CI , −2.1 to −0.1 ; P = .03 ) , increased the risk of pneumothorax requiring drainage ( 3.2 % vs 1.2 % ; difference , 2.0 % ; 95 % CI , 0.0 % to 4.0 % ; P = .03 ) , and the risk of barotrauma ( 5.6 % vs 1.6 % ; difference , 4.0 % ; 95 % CI , 1.5 % to 6.5 % ; P = .001 ) . There were no significant differences in the length of ICU stay , length of hospital stay , ICU mortality , and in-hospital mortality . Conclusions and Relevance In patients with moderate to severe ARDS , a strategy with lung recruitment and titrated PEEP compared with low PEEP increased 28-day all-cause mortality . These findings do not support the routine use of lung recruitment maneuver and PEEP titration in these patients . Trial Registration clinical trials.gov Identifier : Introduction Alveolar derecruitment may occur during low tidal volume ventilation and may be prevented by recruitment maneuvers ( RMs ) . The aim of this study was to compare two RMs in acute respiratory distress syndrome ( ARDS ) patients . Methods Nineteen patients with ARDS and protective ventilation were included in a r and omized crossover study . Both RMs were applied in each patient , beginning with either continuous positive airway pressure ( CPAP ) with 40 cm H2O for 40 seconds or extended sigh ( eSigh ) consisting of a positive end-expiratory pressure maintained at 10 cm H2O above the lower inflection point of the pressure-volume curve for 15 minutes . Recruited volume , arterial partial pressure of oxygen/fraction of inspired oxygen ( PaO2/FiO2 ) , and hemodynamic parameters were recorded before ( baseline ) and 5 and 60 minutes after RM . All patients had a lung computed tomography ( CT ) scan before study inclusion . Results Before RM , PaO2/FiO2 was 151 ± 61 mm Hg . Both RMs increased oxygenation , but the increase in PaO2/FiO2 was significantly higher with eSigh than CPAP at 5 minutes ( 73 % ± 25 % versus 44 % ± 28 % ; P < 0.001 ) and 60 minutes ( 68 % ± 23 % versus 35 % ± 22 % ; P < 0.001 ) . Only eSigh significantly increased recruited volume at 5 and 60 minutes ( 21 % ± 22 % and 21 % ± 25 % ; P = 0.0003 and P = 0.001 , respectively ) . The only difference between responders and non-responders was CT lung morphology . Eleven patients were considered as recruiters with eSigh ( 10 with diffuse loss of aeration ) and 6 with CPAP ( 5 with diffuse loss of aeration ) . During CPAP , 2 patients needed interruption of RM due to a drop in systolic arterial pressure . Conclusion Both RMs effectively increase oxygenation , but CPAP failed to increase recruited volume . When the lung is recruited with an eSigh adapted for each patient , alveolar recruitment and oxygenation are superior to those observed with CPAP Introduction In acute respiratory distress syndrome ( ARDS ) , adequate positive end-expiratory pressure ( PEEP ) may decrease ventilator-induced lung injury by minimising overinflation and cyclic recruitment-derecruitment of the lung . We evaluated whether setting the PEEP using decremental PEEP titration after an alveolar recruitment manoeuvre ( ARM ) affects the clinical outcome in patients with ARDS . Methods Fifty-seven patients with early ARDS were r and omly assigned to a group given decremental PEEP titration following ARM or a table-based PEEP ( control ) group . PEEP  and  inspired fraction of oxygen ( FiO2 )  in the control group were set according to the table-based combinations of FiO2 and PEEP of the ARDS network , by which we aim ed to achieve a PEEP level compatible with an oxygenation target . In the decremental PEEP titration group , the oxygen saturation and static compliance were monitored as the patients performed the ARM along with the extended sigh method , which is design ed to gradually apply and withdraw a high distending pressure over a prolonged period , and the decremental titration of PEEP . Results The baseline characteristics did not differ significantly between the control and decremental PEEP titration groups . Initial oxygenation improved more in the decremental PEEP titration group than in the control group . However , dynamic compliance , tidal volume and PEEP were similar in the two groups during the first week . The duration of use of paralysing or sedative agents , mechanical ventilation , stay in the intensive care unit and mortality at 28 days did not differ significantly between the decremental PEEP titration and control groups . Conclusions The daily decremental PEEP titration after ARM showed only initial oxygenation improvement compared with the table-based PEEP method . Respiratory mechanics and patient outcomes did not differ between the decremental PEEP titration and control groups . Trial registration Clinical Trials.gov identifier : IS RCT N79027921 Introduction Tidal volume and plateau pressure minimisation are the st and ard components of a protective lung ventilation strategy for patients with acute respiratory distress syndrome ( ARDS ) . Open lung strategies , including higher positive end-expiratory pressure ( PEEP ) and recruitment manoeuvres to date have not proven efficacious . This study examines the effectiveness and safety of a novel open lung strategy , which includes permissive hypercapnia , staircase recruitment manoeuvres ( SRM ) and low airway pressure with PEEP titration . Method Twenty ARDS patients were r and omised to treatment or ARDSnet control ventilation strategies . The treatment group received SRM with decremental PEEP titration and targeted plateau pressure < 30 cm H2O . Gas exchange and lung compliance were measured daily for 7 days and plasma cytokines in the first 24 hours and on days 1 , 3 , 5 and 7 ( mean ± SE ) . Duration of ventilation , ICU stay and hospital stay ( median and interquartile range ) and hospital survival were determined . Results There were significant overall differences between groups when considering plasma IL-8 and TNF-α . For plasma IL-8 , the control group was 41 % higher than the treatment group over the seven-day period ( ratio 1.41 ( 1.11 to 1.79 ) , P = 0.01 ) , while for TNF-α the control group was 20 % higher over the seven-day period ( ratio 1.20 ( 1.01 to 1.42 ) P = 0.05 ) . PaO2/FIO2 ( 204 ± 9 versus 165 ± 9 mmHg , P = 0.005 ) and static lung compliance ( 49.1 ± 2.9 versus 33.7 ± 2.7 mls/cm H2O , P < 0.001 ) were higher in the treatment group than the control group over seven days . There was no difference in duration of ventilation ( 180 ( 87 to 298 ) versus 341 ( 131 to 351 ) hrs , P = 0.13 ) , duration of ICU stay ( 9.9 ( 5.6 to 14.8 ) versus 16.0 ( 8.1 to 19.3 ) days , P = 0.19 ) and duration of hospital stay ( 17.9 ( 13.7 to 34.5 ) versus 24.7 ( 20.5 to 39.8 ) days , P = 0.16 ) between the treatment and control groups . Conclusions This open lung strategy was associated with greater amelioration in some systemic cytokines , improved oxygenation and lung compliance over seven days . A larger trial powered to examine clinical ly-meaningful outcomes is warranted . Trial registration BACKGROUND In the acute respiratory distress syndrome ( ARDS ) , positive end-expiratory pressure ( PEEP ) may decrease ventilator-induced lung injury by keeping lung regions open that otherwise would be collapsed . Since the effects of PEEP probably depend on the recruitability of lung tissue , we conducted a study to examine the relationship between the percentage of potentially recruitable lung , as indicated by computed tomography ( CT ) , and the clinical and physiological effects of PEEP . METHODS Sixty-eight patients with acute lung injury or ARDS underwent whole-lung CT 
    Output:
    