• Barbas Carmen Sílvia Valente CS Division of Pulmonary and Critical Care, University of São Paulo, São Paulo, Brazil; and Intensive Care Unit, Albert Einstein Hospital, Sã, Gustavo Faissol Janot de Matos, Mariangela Pimentel Pincelli, Eduardo da Rosa Borges, Telma Antunes, Juliana Monteiro de Barros, Valdelis Okamoto, João Batista Borges, Marcelo Brito Passos Amato, and Carlos Roberto Ribeiro de Carvalho.
• Division of Pulmonary and Critical Care, University of São Paulo, São Paulo, Brazil; and Intensive Care Unit, Albert Einstein Hospital, São Paulo, Brazil. cbarbas@attglobal.net
• Curr Opin Crit Care. 2005 Feb 1; 11 (1): 18-28.

Purpose Of ReviewTo review as best the critical care clinicians can recruit the acute respiratory distress syndrome (ARDS) lungs and keep the lungs opened, assuring homogeneous ventilation, and to present the experimental and clinical results of these mechanical ventilation strategies, along with possible improvements in patient outcome based on selected published medical literature from 1972 to 2004 (highlighting the period from June 2003 to June 2004 and recent results of the authors' group research).Recent FindingsIn the experimental setting, repeated derecruitments accentuate lung injury during mechanical ventilation, whereas open lung concept strategies can attenuate lung injury. In the clinical setting, recruitment maneuvers improve short-term oxygenation in ARDS patients. A recent prospective clinical trial showed that low versus intermediate positive end-expiratory pressure (PEEP) levels (8 vs 13 cm H2O) associated with low tidal ventilation had the same effect on ARDS patient survival. Nevertheless, both conventional and electrical impedance thoracic tomography studies indicate that stepwise PEEP recruitment maneuvers increase lung volume and the recruitment percentage of lung tissue, and higher levels of PEEP (18-26 cm H2O) are necessary to keep the ARDS lungs opened and assure a more homogeneous low tidal ventilation.SummaryStepwise PEEP recruitment maneuvers can open collapsed ARDS lungs. Higher levels of PEEP are necessary to maintain the lungs open and assure homogenous ventilation in ARDS. In the near future, thoracic CT associated with high-performance monitoring of regional ventilation (electrical impedance tomography) may be used at the bedside to determine the optimal mechanical ventilation of ARDS patients.

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