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Evevident
Original paper
2000NEJMPulmonary/Critical Care

ARDSNet ARMA

Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome

RCTARDS

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Overview

Low tidal-volume ventilation reduced mortality in acute lung injury/ARDS.

Clinical takeaway

ARDSNet ARMA made lung-protective ventilation the default ventilator strategy in ARDS: 6 mL/kg predicted body weight with plateau pressure limitation.

Key result

Mortality was 31.0% with 6 mL/kg vs 39.8% with 12 mL/kg tidal volumes.

Practice impact

Low tidal-volume lung-protective ventilation became standard of care for ARDS.

Evidence

Study design

Randomized controlled trial (stopped early for efficacy).

Enrollment

861

Follow-up

To hospital discharge or 180 days.

Geography

United States

Clinical question

Does lower tidal-volume ventilation improve survival in acute lung injury/ARDS?

Population

  • Mechanically ventilated patients with acute lung injury or ARDS.

Intervention

Low tidal volume ventilation targeting 6 mL/kg predicted body weight with plateau pressure <=30 cm H2O.

Comparator

Traditional tidal volume ventilation targeting 12 mL/kg predicted body weight.

Primary outcome

Death before discharge home with unassisted breathing.

Ventilation with 6 mL/kg predicted body weight reduced mortality from 39.8% to 31.0% compared with traditional 12 mL/kg volumes.

Absolute mortality reduction / 8.8 / p=0.007

Key results

  • In-hospital mortality: 31.0% with 6 mL/kg vs 39.8% with 12 mL/kg (p=0.007), an absolute reduction of ~9 percentage points.
  • Ventilator-free days in the first 28 days were higher with low tidal volume (12 vs 10; p=0.007).
  • The trial was stopped early after enrolling 861 of a planned larger sample.

Harms

  • Lower tidal volumes caused more early respiratory acidosis, managed with higher respiratory rates and bicarbonate.
  • No excess barotrauma was seen with the lung-protective strategy.

Clinical Use

When to cite

  • When setting invasive ventilation for ARDS and explaining why tidal volume should be based on predicted body weight.

Practice impact

  • Low tidal-volume lung-protective ventilation became standard of care for ARDS.

Applicability

  • Most applicable to mechanically ventilated patients with acute lung injury or ARDS.

Limitations

  • ARDS definitions and co-interventions have evolved since 2000.
  • Requires dosing tidal volume on predicted (not actual) body weight, which is often miscalculated at the bedside.
  • Single strategy; PEEP, proning, and neuromuscular blockade were later studied separately.

Common misinterpretations

  • Tidal volume must be set on predicted body weight (from height and sex), not the patient's measured weight.
  • The benefit is a mortality reduction, not merely improved oxygenation; oxygenation was actually lower early in the low-volume group.

Related evidence

PROSEVA - Same Disease

Citation

Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-1308. doi:10.1056/NEJM200005043421801

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.