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 Objective To assess how the level of positive end-expiratory pressure ( PEEP ) ( antiderecruitment strategy ) , etiological category of diffuse lung injury , and body position of the patient modify the effect of the alveolar recruitment maneuver ( ARM ) in acute respiratory distress syndrome ( ARDS ) . Design Prospect i ve clinical trial . Setting Medical intensive care unit at a tertiary hospital . Patients Forty-seven patients with early ARDS , including 19 patients from our preliminary study . InterventionFrom baseline ventilation at a tidal volume of 8 mL/kg and PEEP of 10 cm H2O , the ARM ( a stepwise increase in the level of PEEP up to 30 cm H2O with a concomitant decrease in the magnitude of tidal volume down to 2 mL/kg ) was given with ( ARM + PEEP , n = 20 ) or without ( ARM only , n = 19 ) subsequent increase of PEEP to 15 cm H2O . In eight other patients , PEEP was increased to 15 cm H2O without a preceding ARM ( PEEP only ) . Measurements and Results In all three groups , Pao2 was increased by the respective intervention ( all p < .05 ) . In the ARM-only group , Pao2 at 15 mins after intervention was lower than Pao2 immediate after intervention ( p = .046 ) . In the ARM + PEEP group , no such decrease in Pao2 was observed , and Pao2 at 15 , 30 , 45 , and 60 mins after intervention was higher than in the ARM-only group ( all p < .05 ) . Compared with the PEEP-only group , Pao2 of the ARM + PEEP group was higher immediately after intervention and at the later time points ( all p < .05 ) . Compared with patients with ARDS associated with direct lung injury ( pulmonary ARDS ) , patients with ARDS associated with indirect lung injury ( extrapulmonary ARDS ) showed a greater increase in Pao2 ( 27 ± 21 % vs. 130 ± 112%;p = .002 ) and a greater decrease in radiologic scores ( 1.0 ± 2.4 vs. 3.4 ± 1.5;p = .005 ) after the ARM . The increase in Pao2 induced by the ARM was greater for patients in the supine position than for patients in the prone position ( 61 ± 82 % vs. 21 ± 14%;p = .028 ) . Consequently , Pao2 immediately after the ARM was similar in the two groups of patients in different positions . Conclusions After the ARM , a sufficient level of PEEP is required as an antiderecruitment strategy . Pulmonary ARDS and extrapulmonary ARDS may be different pathophysiologic entities . An effective ARM may obviate the need for the prone position in ARDS at least in terms of oxygenation Background Biologically variable ventilation ( return of physiological variability in rate and tidal volume using a computer-controller ) was compared to control mode ventilation with and without a recruitment manoeuvre – 40 cm H2O for 40 sec performed hourly ; in a porcine oleic acid acute lung injury model . Methods We compared gas exchange , respiratory mechanics , and measured bronchoalveolar fluid for inflammatory cytokines , cell counts and surfactant function . Lung injury was scored by light microscopy . Pigs received mechanical ventilation ( FIO2 = 0.3 ; PEEP 5 cm H2O ) in control mode until PaO2 decreased to 60 mm Hg with oleic acid infusion ( PaO2/FIO2 < 200 mm Hg ) . Additional PEEP to 10 cm H2O was added after injury . Animals were r and omized to one of the 3 modes of ventilation and followed for 5 hr after injury . Results PaO2 and respiratory system compliance was significantly greater with biologically variable ventilation compared to the other 2 groups . Mean and mean peak airway pressures were also lower . There were no differences in cell counts in bronchoalveolar fluid by flow cytometry , or interleukin-8 and -10 levels between groups . Lung injury scoring revealed no difference between groups in the regions examined . No differences in surfactant function were seen between groups by capillary surfactometry . Conclusions In this porcine model of acute lung injury , various indices to measure injury or inflammation did not differ between the 3 approaches to ventilation . However , when using a low tidal volume strategy with moderate levels of PEEP , sustained improvements in arterial oxygen tension and respiratory system compliance were only seen with BVV when compared to CMV or CMV with a recruitment manoeuvre BACKGROUND Traditional approaches to mechanical ventilation use tidal volumes of 10 to 15 ml per kilogram of body weight and may cause stretch-induced lung injury in patients with acute lung injury and the acute respiratory distress syndrome . We therefore conducted a trial to determine whether ventilation with lower tidal volumes would improve the clinical outcomes in these patients . METHODS Patients with acute lung injury and the acute respiratory distress syndrome were enrolled in a multicenter , r and omized trial . The trial compared traditional ventilation treatment , which involved an initial tidal volume of 12 ml per kilogram of predicted body weight and an airway pressure measured after a 0.5-second pause at the end of inspiration ( plateau pressure ) of 50 cm of water or less , with ventilation with a lower tidal volume , which involved an initial tidal volume of 6 ml per kilogram of predicted body weight and a plateau pressure of 30 cm of water or less . The primary outcomes were death before a patient was discharged home and was breathing without assistance and the number of days without ventilator use from day 1 to day 28 . RESULTS The trial was stopped after the enrollment of 861 patients because  mortality was lower in the group treated with lower tidal volumes than in the group treated with traditional tidal volumes ( 31.0 percent vs. 39.8 percent , P=0.007 ) , and the number of days without ventilator use during the first 28 days after r and omization was greater in this group ( mean [ + /-SD ] , 12+/-11 vs. 10+/-11 ; P=0.007 ) . The mean tidal volumes on days 1 to 3 were 6.2+/-0.8 and 11.8+/-0.8 ml per kilogram of predicted body weight ( P<0.001 ) , respectively , and the mean plateau pressures were 25+/-6 and 33+/-8 cm of water ( P<0.001 ) , respectively . CONCLUSIONS In patients with acute lung injury and the acute respiratory distress syndrome , mechanical ventilation with a lower tidal volume than is traditionally used results in decreased mortality and increases the number of days without ventilator use 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 
    Output:
    
agent
***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 Objective To assess how the level of positive end-expiratory pressure ( PEEP ) ( antiderecruitment strategy ) , etiological category of diffuse lung injury , and body position of the patient modify the effect of the alveolar recruitment maneuver ( ARM ) in acute respiratory distress syndrome ( ARDS ) . Design Prospect i ve clinical trial . Setting Medical intensive care unit at a tertiary hospital . Patients Forty-seven patients with early ARDS , including 19 patients from our preliminary study . InterventionFrom baseline ventilation at a tidal volume of 8 mL/kg and PEEP of 10 cm H2O , the ARM ( a stepwise increase in the level of PEEP up to 30 cm H2O with a concomitant decrease in the magnitude of tidal volume down to 2 mL/kg ) was given with ( ARM + PEEP , n = 20 ) or without ( ARM only , n = 19 ) subsequent increase of PEEP to 15 cm H2O . In eight other patients , PEEP was increased to 15 cm H2O without a preceding ARM ( PEEP only ) . Measurements and Results In all three groups , Pao2 was increased by the respective intervention ( all p < .05 ) . In the ARM-only group , Pao2 at 15 mins after intervention was lower than Pao2 immediate after intervention ( p = .046 ) . In the ARM + PEEP group , no such decrease in Pao2 was observed , and Pao2 at 15 , 30 , 45 , and 60 mins after intervention was higher than in the ARM-only group ( all p < .05 ) . Compared with the PEEP-only group , Pao2 of the ARM + PEEP group was higher immediately after intervention and at the later time points ( all p < .05 ) . Compared with patients with ARDS associated with direct lung injury ( pulmonary ARDS ) , patients with ARDS associated with indirect lung injury ( extrapulmonary ARDS ) showed a greater increase in Pao2 ( 27 ± 21 % vs. 130 ± 112%;p = .002 ) and a greater decrease in radiologic scores ( 1.0 ± 2.4 vs. 3.4 ± 1.5;p = .005 ) after the ARM . The increase in Pao2 induced by the ARM was greater for patients in the supine position than for patients in the prone position ( 61 ± 82 % vs. 21 ± 14%;p = .028 ) . Consequently , Pao2 immediately after the ARM was similar in the two groups of patients in different positions . Conclusions After the ARM , a sufficient level of PEEP is required as an antiderecruitment strategy . Pulmonary ARDS and extrapulmonary ARDS may be different pathophysiologic entities . An effective ARM may obviate the need for the prone position in ARDS at least in terms of oxygenation Background Biologically variable ventilation ( return of physiological variability in rate and tidal volume using a computer-controller ) was compared to control mode ventilation with and without a recruitment manoeuvre – 40 cm H2O for 40 sec performed hourly ; in a porcine oleic acid acute lung injury model . Methods We compared gas exchange , respiratory mechanics , and measured bronchoalveolar fluid for inflammatory cytokines , cell counts and surfactant function . Lung injury was scored by light microscopy . Pigs received mechanical ventilation ( FIO2 = 0.3 ; PEEP 5 cm H2O ) in control mode until PaO2 decreased to 60 mm Hg with oleic acid infusion ( PaO2/FIO2 < 200 mm Hg ) . Additional PEEP to 10 cm H2O was added after injury . Animals were r and omized to one of the 3 modes of ventilation and followed for 5 hr after injury . Results PaO2 and respiratory system compliance was significantly greater with biologically variable ventilation compared to the other 2 groups . Mean and mean peak airway pressures were also lower . There were no differences in cell counts in bronchoalveolar fluid by flow cytometry , or interleukin-8 and -10 levels between groups . Lung injury scoring revealed no difference between groups in the regions examined . No differences in surfactant function were seen between groups by capillary surfactometry . Conclusions In this porcine model of acute lung injury , various indices to measure injury or inflammation did not differ between the 3 approaches to ventilation . However , when using a low tidal volume strategy with moderate levels of PEEP , sustained improvements in arterial oxygen tension and respiratory system compliance were only seen with BVV when compared to CMV or CMV with a recruitment manoeuvre BACKGROUND Traditional approaches to mechanical ventilation use tidal volumes of 10 to 15 ml per kilogram of body weight and may cause stretch-induced lung injury in patients with acute lung injury and the acute respiratory distress syndrome . We therefore conducted a trial to determine whether ventilation with lower tidal volumes would improve the clinical outcomes in these patients . METHODS Patients with acute lung injury and the acute respiratory distress syndrome were enrolled in a multicenter , r and omized trial . The trial compared traditional ventilation treatment , which involved an initial tidal volume of 12 ml per kilogram of predicted body weight and an airway pressure measured after a 0.5-second pause at the end of inspiration ( plateau pressure ) of 50 cm of water or less , with ventilation with a lower tidal volume , which involved an initial tidal volume of 6 ml per kilogram of predicted body weight and a plateau pressure of 30 cm of water or less . The primary outcomes were death before a patient was discharged home and was breathing without assistance and the number of days without ventilator use from day 1 to day 28 . RESULTS The trial was stopped after the enrollment of 861 patients because  mortality was lower in the group treated with lower tidal volumes than in the group treated with traditional tidal volumes ( 31.0 percent vs. 39.8 percent , P=0.007 ) , and the number of days without ventilator use during the first 28 days after r and omization was greater in this group ( mean [ + /-SD ] , 12+/-11 vs. 10+/-11 ; P=0.007 ) . The mean tidal volumes on days 1 to 3 were 6.2+/-0.8 and 11.8+/-0.8 ml per kilogram of predicted body weight ( P<0.001 ) , respectively , and the mean plateau pressures were 25+/-6 and 33+/-8 cm of water ( P<0.001 ) , respectively . CONCLUSIONS In patients with acute lung injury and the acute respiratory distress syndrome , mechanical ventilation with a lower tidal volume than is traditionally used results in decreased mortality and increases the number of days without ventilator use 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 
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