3100 Chin Med J 2010;123(21):3100-3105

Original article
Clinical efficacy and safety of recruitment maneuver in patients
with acute respiratory distress syndrome using low tidal volume
ventilation: a multicenter randomized controlled clinical trial
XI Xiu-ming, JIANG Li, ZHU Bo and the RM group

Keywords: respiratory distress syndrome, adult; respiration, artificial; recruitment maneuver;

positive-pressure respiration; randomized controlled trial

Background The recruitment maneuver (RM) has been shown to improve oxygenation in some patients with acute
respiratory distress syndrome. But there is a lack of standardization and lack of clinical studies to prove the improvement
on clinical outcome. We conducted this study to evaluate the clinical efficacy and safety of the RM in patients with acute
respiratory distress syndrome (ARDS) using low tidal volume ventilation.
Methods We randomly assigned 110 patients with ARDS from 14 Chinese intensive care units (ICUs) at the tertiary
teaching hospitals. Patients with PaO 2 ≤200 mmHg at FiO 2 1.0 and PEEP ≥10 cmH 2 O were included in the study.
Patients were randomized into two groups: control group and RM group. The tidal volume was set to 6–8 ml per kilogram
of predicted body weight (PBW) in both groups. RM was performed by continuous positive airway pressure (CPAP) of 40
cmH 2 O maintained for 40 seconds. RMs was conducted every eight hours for the first five days, or stopped within five
days if the patient reached the weaning standard.
Results One hundred and ten patients had completed the requirements for the primary study goals, 55 from the RM
group and 55 control patients. Baseline characteristics remained similar in the two groups. In the RM group the
PaO 2 /FiO 2 was significantly increased compared to baseline at 120 minutes after RM on day one and day two (P=0.007
and P=0.001). There were no significant differences between the RM and control group in hospital mortality (41.8% vs.
56.4%, P=0.13), 28-day mortality (29.1% vs. 43.6%, P=0.11) and ventilator-free days at day 28 (10.8±10.1 vs. 7.4±10.0,
P=0.08). ICU mortality (32.7% vs. 52.7%, P=0.03), the rate of survival with unassisted breathing for at least 48
consecutive hours at day 28 (58.2% vs. 36.2%, P=0.02), and nonpulmonary organ failure-free days at day 28 (17.4±11.1
vs. 13.0±12.0, P=0.03) favored the RM group. There was no significant difference in mean blood pressure and heart rate
before RM and at 30, 60, 120 minutes after RM. There was no incidence of barotraumas.
Conclusions RM was safe and useful for improving oxygenation in patients with ARDS who were ventilated with a low
tidal volume, with a beneficial impact on their clinical outcome.
Chin Med J 2010;123(21):3100-3105

A cute respiratory distress syndrome (ARDS) is one of

the most challenging complications in critically ill
patients. Despite advances in intensive care medicine, the
mortality of ARDS remains about 50%.1 Recent studies2,3
have reported improved outcome for patients with ARDS
ventilated with lung-protective ventilation support. But
lung alveolar derecruitment induced by the reduction in
tidal volume is now well documented and represents the
price of lung protective strategies.4 The recruitment
maneuver (RM) is a strategy aimed at re-expanding
collapsed lung tissue, and then maintaining high positive
end-expiratory pressure (PEEP) to prevent subsequent
de-recruitment. Although a few clinical reports have been
published on the RM technique,2,5-9 the effectiveness of
the RM has not been determined in ARDS patients. The
purpose of this study was to assess the efficacy and safety
of RM with low tidal volume ventilation in patients
suffering from ARDS.
METHODS
Patients and definitions
The study protocol was approved by the institutional
review board of the ethics committee, and informed
consent was obtained from each patient or next of kin. All
patients admitted to the 14 Intensive Care Units (ICU) at
tertiary teaching hospitals in China from March 2003 to
September 2006 were screened for entry into the study.
Patients who were intubated and received mechanical
ventilation were eligible for the study if they had an acute
decrease in arterial oxygen (PaO 2 ) to 200 mmHg or less
(PEEP 10 cmH 2 O, FiO 2 1.0, after 30 minutes), bilateral
pulmonary infiltrates on a chest radiograph consistent
with the presence of edema, and no clinical evidence of
left atrial hypertension or (if measured) a pulmonary-
capillary wedge pressure of 18 mmHg or less, age >18
years, and stable hemodynamics. Patients with history of
acute myocardial infarction within the preceding week,
DOI: 10.3760/cma.j.issn.0366-6999.2010.21.027
Intensive Care Unit, Fuxing Hospital, Capital Medical University,
Beijing 100038, China (Xi XM, Jiang L and Zhu B)
Correspondence to: Prof. XI Xiu-ming, Intensive Care Unit, Fuxing
Hospital, Capital Medical University, Beijing 100038, China (Tel:
86-10-88062937. Fax: 86-10-63263158. Email: xxm2937@sina.com)
Chinese Medical Journal 2010;123(21):3100-3105
preexisting chronic respiratory insufficiency (chronic
obstructive pulmonary disease, asthma, restrictive
respiratory insufficiency), anatomic chest wall
abnormalities, chest tube with persistent air leak,
pneumothorax or bronchopleural fistula, a gross
barotrauma in any form (subcutaneous emphysema,
pneumomediastinum), pregnancy, malignant disease or
end-stage chronic diseases, anatomical lobectomy within
two weeks, bone marrow transplant or lung transplantation,
chronic liver disease (as defined by Child-Pugh class C),
intracranial pressure or neuromuscular disease that could
impair spontaneous breathing, having been included in the
same study, or participation in other studies were excluded
from the study.
Randomization was achieved from computer-generated
random numbers, which were then stored in sealed
envelopes. The patients were randomly assigned to either
the group treated with the RM and low tidal volume (RM
group) or the group treated with a low tidal volume
without RM (control group).
Ventilation protocol
The volume-controlled or pressure-controlled mode was
requested to be used in the first 24 hours. Another
ventilation mode could be chosen in the following days,
but pressure support ventilation (PSV) was preferred. The
tidal volume was set to 6–8 ml per kilogram of predicted
body weight (PBW)3 to maintain plateau pressure at a
level of no more than 30 cmH 2 O. The minimal tidal
volume was 4 ml PBW. The level of PEEP were based on
the patient’s underlying clinical condition to obtain an
arterial oxygen saturation (SaO 2 ) value of 90%–95% or
PaO 2 of 60–80 mmHg or both, with nontoxic FiO 2 values
of ≤0.60. The highest respiratory rate was less than
35/min allowing maintenance of partial pressure of
arterial carbon dioxide (PaCO 2 ) at a level of mild
permissive hypercapnia between 45–50 mmHg or an
arterial pH of 7.30–7.45.
RM
All patients were adequately sedated (Ramsay 4–5) with
stable hemodynamics (systolic blood pressure 100–200
mmHg, heart rate 70–140/min) before RM.
Neuromuscular blocking drugs could be used if needed.
The FiO 2 was set at 1.0 for five minutes. RM was
performed by changing the ventilator mode to continuous
positive airway pressure (CPAP) and gradually increasing
the CPAP over 10 seconds to 40 cmH 2 O which was
maintained for 40 seconds. The CPAP level then was
decreased over 5 seconds and returned to the initial
ventilator settings (mode, PEEP, and FiO 2 ). RMs were
conducted every eight hours for the first five successive
days, or stopped within five days if the patient reached
the weaning standard. RMs were stopped if any of the
following events occurred: heart rate increased to
≥140/min or by >20/min, systolic blood pressure
decreased to ≤90 mmHg or by >30 mmHg,
oxyhemoglobin saturation measured by pulse oximetry
(SpO 2 ) was <90% and had decreased by >5%, or
3101
barotrauma of any form was detected by chest
radiography.
Serum interleukin (IL)-6
Blood samples were obtained before randomization (day
0) and on days 3 and 5 for the measurement of serum
IL-6 concentration by enzyme-linked immunoassay.
Data collection
Data compiled from each patient included the followings:
demographic information, clinical conditions associated
with the development of ARDS, routine laboratory
measurements, pulmonary physiologic and ventilatory
measurements (including arterial blood gas, ventilator
mode, tidal volume, PEEP, plateau pressure, peak
pressure, and FiO 2 ), chest radiographic, cardiovascular
data, the number of extrapulmonary organ failures before
and after randomization, complications and adverse
events. Physiologic, radiographic and respiratory data
were recorded from day 1 to day 5.
The primary outcome was ICU mortality. Secondary
outcome variables included the number of ventilator-free
days, nonpulmonary organ-dysfunction-free days from
day 1 to day 28, 28-day mortality, the percentage of
unassisted breathing hours for at least 48 consecutive
hours, the incidence of barotrauma (defined as any new
pneumothorax, pneumomediastinum, or subcutaneous
emphysema), or a pneumatocele that was more than 2 cm
in diameter.
Statistical analysis
Statistical analysis was performed using the SAS version
8.0 (SAS Institution). The values for the IL-6
concentrations were not normally distributed so we
performed log 10 transformations to normalize the data to
permit the application of parametric statistics. All
continuous data are presented as mean ± standard
deviation (SD) or median (25th–75th percentile) as
appropriate. The statistical significance of the values at
different time points after RM in the two groups was
evaluated by repeated-measures analysis of variance
models. To evaluate differences between the two groups,
the Fisher exact test for categorical variables, the t test
with equal variance for continuous variables, and the
Mann-Whitney rank sum test for ordinal variables were
used. The difference of hospital survival rate between the
RM group and control group was compared by
Kaplan-Meier survival analysis methods with the
log-rank test. A P <0.05 was considered statistically
significant.
RESULTS
One hundred and twenty-five patients were enrolled in
the study; 110 patients completed data forms for the
primary study goals, 55 in the RM group and 55 in the
control group, 15 patients were withdrawn from the study
(Figure 1). The baseline characteristics of the 110 patients
were similar (Table 1).
3102 Chin Med J 2010;123(21):3100-3105

day 28 were higher in the RM group, 17.4±11.1 vs

13.0±12.0 (P=0.03). The number of ventilator-free days
(10.8±10.1 vs. 7.4±10.0, P=0.08), and hospital stay
((43.2±45.6) days vs (33.2±34.0) days, P=0.12) were
similar in the two groups. But the lengths of ICU stay of
(22.5±22.2) days vs. (19.8±24.8) days (P=0.02) was
longer in RM group (Table 5). The 28-day survival rate
between the two groups was compared by Kaplan-Meier
curve (Long Rank, P=0.947, Figure 3).

Changes in mean blood pressure and heart rate were not

Figure 1. Flow diagram illustrating patients meeting entry
criteria to patients included in final analysis.
significantly different before RM and at 30, 60, and 120
minutes after RM. RM was terminated early in only one
case because of hypotension, which was transient and
self-limiting after RM. No barotrauma was reported.

Table 1. Comparison of baseline characteristics between the two DISCUSSION

groups (mean ± SD or median (25th–75th percentile))
Characteristics
RM group Control group P This trial did not show a significant benefit in hospital
（n=55） （n=55） values mortality and 28-day mortality. We think that this was
Age (year) 62.2±16.0 65.5±15.2 0.28
partly due to the heterogeneity of the patients, lower
Male (n (%)) 38 (69.1) 40 (72.7) 0.68
APACHE II score 21.5±6.7 23.1±8.6 0.28
post-RM PEEP level, small sample number, and for some
Tidal volume (ml/kg of PBW) 6.6±0.9 6.8±1.1 0.39 patients, perhaps the CPAP level of RM was not high
PEEP (cmH 2 O) 10.5±3.2 9.7±2.4 0.18 enough to open the collapsed alveolar. However, we
Ppeak (cmH 2 O) 28.0±5.9 27.9±6.8 0.94 found that the use of low tidal volume plus periodic RM
Pplat (cmH 2 O) 24.2±5.3 23.4±5.3 0.47
improved the survival with unassisted breathing and
Respiratory rate (breaths/min) 27.3±8.0 26.5±9.1 0.39
PaO 2 /FiO 2 93.8 (68.7–150.0) 120.0 (88.3–140.0) 0.06
decreased ICU mortality in ARDS patients. We ascribe
Causes of ARDS (n (%)) the better outcome to the higher rates of weaning from the
Pneumonia 19 (34.5) 17 (30.9) ventilator and lower rates of organ dysfunction.
Aspiration 6 (10.9) 4 (7.3)
Sepsis 7 (12.7) 16 (29.1)
The severity of organ dysfunction is an important factor
Trauma 2 (3.6) 3 (5.5)
Others 21 (38.2) 15 (27.3)
in prognosis and the leading cause of death in patients
APACHE II: Acute Physiology Chronic Health Evaluation; PBW: predicted body with ARDS.10,11 This trial showed that the number of days
weight; PEEP: positive end-expiratory pressure; Ppeak: airway peak pressure; without nonpulmonary organ failure were significantly
Pplat: airway plateau pressure; PaO 2 : partial pressure of arterial oxygen; FiO 2 : higher (17.4±11.1 vs 13.0±12.0, P=0.03) in the RM group
fraction of inspired oxygen. compared with the control group. Slutsky et al11 explored
the hypothesis that mechanical ventilation may play a
There were no significant differences in the ventilator pivotal role in the initiation and/or propagation of a
parameters and arterial blood gas between the two groups systemic inflammatory response leading to multiorgan
in the first five days (Tables 2 and 3). The PaO 2 /FiO 2 dysfunction syndrome (MODS) and have a significant
ratio and PaO 2 showed a consistent and significant effect on mortality. The improvement of organ function
increase in both groups. The PaO 2 /FiO 2 increased may play an important role in survival in ARDS patients.
significantly at 120 minutes after RM on days one and In addition, the data showed that the RM group had more
two compared to baseline (P=0.007, P=0.001, ventilator-free days (10.8±10.1 vs. 7.4±10.0, P=0.08) and
respectively), but the differences became gradually a significantly higher rate of survival with unassisted
smaller in the following three days (Figure 2). The mean breathing for at least 48 consecutive hours at day 28
log-transformed serum IL-6 concentration decreased from (58.2% vs. 36.4%, P=0.02). Those who were weaned may
day one to day five in both groups. Serum IL-6 accrue an additional benefit from avoiding mechanical
concentration on days 1, 3, and 5 were similar (Table 4). ventilation-induced lung injury and infection and other
complications.
There were no significant differences between the RM
and control groups in hospital mortality (41.8% vs. 56.4%, Recruitment is a dynamic process that refers to the
P=0.13) and 28-day mortality (29.1% vs. 43.6%, P=0.11). opening of previously collapsed lung units that is forced
ICU mortality for patients with RM was significantly by an increase in transpulmonary pressure. It avoids shear
lower (32.7% vs. 52.7%, P=0.03). The rate of survival stress at the epithelium of the alveolar walls caused by the
with unassisted breathing for at least 48 consecutive cyclic opening and closing of unstable lung units.12-14
hours at day 28 was 58.2% for the RM group vs. 36.4% Other investigators have shown that lung protective
for the controls (P=0.02), and the number of ventilation strategies are associated with lower
nonpulmonary organ failure free-days from day one to concentrations of inflammatory cytokines and mediators
 Chinese Medical Journal 2010;123(21):3100-3105 3103

Table 2. Comparison of ventilator parameters between the two groups (mean ± SD)
Day 1 Day 2 Day 3 Day 4 Day5
Variables RM group Control group RM group Control group RM group Control group RM group Control group RM group Control group
(n=55) (n=55) (n=55) (n=55) (n=55) (n=55) (n=55) (n=55) (n=55) (n=55)
Tidal volume 6.4±0.6 6.3±0.7 6.4±0.9 6.4±0.8 6.5±0.9 6.4±0.9 6.6±0.8 6.7±0.7 6.6±0.7 6.8±0.8
(ml/kg of PBW)
RR (breaths/min) 28.7±7.9 30.8±8.8 25.0±6.3 26.5±8.8 25.7±6.1 26.4±7.0 25.2±6.9 25.6±7.4 25.3±7.4 25.7±6.9
Pplat (cm H 2 O) 24.2±5.3 23.4±5.3 21.6±5.1 22.0±5.6 20.7±5.3 22.0±5.0 20.1±6.0 21.6±6.5 20.7±5.7 21.7±6.1
Ppeak (cm H 2 O) 28.0±5.9 27.9±6.9 26.0±5.9 26.7±5.8 25.1±5.9 26.5±5.8 24.4±5.6 25.6±6.5 24.5±5.9 25.8±6.5
PEEP (cm H 2 O) 10.5±3.2 9.8±2.3 10.4±3.3 9.7±2.5 10.2±3.4 9.4±2.8 9.0±3.1 8.7±2.9 8.8±3.0 8.1±3.0
FiO 2 0.61±0.19 0.64±0.21 0.53±0.16 0.52±0.12 0.50±0.14 0.49±0.10 0.48±0.14 0.49±0.15 0.47±0.14 0.45±0.12
RR: respiratory rate; Pplat: plateau airway pressure; Ppeak: peak airway pressure; PEEP: positive end-expiratory pressure; FiO 2 : fraction of inspired oxygen.

Table 3. Comparison of arterial blood variables between the two groups (mean ± SD or median (25th-75th percentile))
Day 1 Day 2 Day 3 Day 4 Day 5
Variables RM group Control group RM group Control group RM group Control group RM group Control group RM group Control group
(n=55) (n=55) (n=55) (n=55) (n=55) (n=55) (n=55) (n=55) (n=55) (n=55)
PH 7.41±0.11 7.37±0.11 7.42±0.08 7.39±0.11 7.43±0.08 7.39±0.10 7.42±0.10 7.39±0.10 7.42±0.09 7.40±0.07
PaCO 2 35.7±11.6 40.8±15.3 36.9±9.8 39.0±11.0 35.9±9.0 40.4±11.9 37.1±10.4 40.1±11.5 37.1±8.7 38.8±9.2
(mmHg)
PaO 2 * 75.9 66.5 82.4 80.9 85.4 83.2 91.4 86.0 89.6 86.4
(mmHg) (62.7–90.6) (60.0–91.1) (70.0–104.0) (70.0–87.7) (68.0–107.4) (72.3–102.6) (70.5–109.8） （73.7–111.6） （70.9–115.3）(70.7–105.0）
PaO 2 /FiO 2 * 132.4 123.0 183.1 152.4 188.9 167.6 200.7 192.8 206.9 197.1
(mmHg) (104.5–175.8) (92.3–165.1) (122.7–223.3) (120.0–202.2) (124.0–243.8) (144.6–218.0) (148.9–256.5) (152.6–246.5) (151.7–260.0) (150.6–245.6)
PaCO 2 : partial pressure of arterial carbon dioxide; PaO 2 : partial pressure of arterial oxygen. *Compared with day 1, PaO 2 and PaO 2 /FiO 2 were increased in the
following days, but there was no significant difference in 2 groups.

improve oxygenation early in the course of treatment for

patients with ARDS.

A sufficiently high level of PEEP is required to prevent

lung volume loss after the recruitment maneuver. Several
studies have suggested that an appropriate PEEP setting
after RM should be in the range of 15–25 cmH 2 O to
maintain the open lung.16,17 Controversy exists regarding
the optimal level of PEEP. Some of the tools that have
been used to define optimal PEEP levels include
Figure 2. Comparison of PaO 2 /FiO 2 before RM and 120 pressure-volume curve analysis and CT scan. However,
minutes after RM. PaO 2 /FiO 2 increased significantly at 120 these tests are difficult to perform at the bedside due to
minutes after RM on day 1 and day 2 compared to baseline their complexity. In our study, the PEEP level was not
(P=0.007, P=0.001, respectively), but the differences were specifically set and was only based on the oxygenation
gradually smaller in following days. condition. The mean PEEP level did not seem too high.
The lower post-RM PEEP level, as previously discussed,
Table 4. Comparison of IL-6 level of two groups on days 1, 3, 5
(mean±SD) was one of the potential reasons for no improvement in
Time RM group Control group P values hospital mortality and 28-day mortality. We think that
Day 1 287.16±269.91 (n=24) 297.54±276.76 (n=23) 0.897 lung compliance may have changed after RM; therefore,
Day 3 207.44±225.44 (n=22) 252.89±261.74 (n=21) 0.545 post-RM PEEP needs to be individualized and should not
Day 5 192.12±211.18 (n=21) 235.87±292.41 (n=19) 0.588 be decreased to the pre-RM PEEP level too quickly.

in the blood and attenuated local and systemic cytokine
response in ARDS patients.3,15 This study has shown that
patients in the RM group had a reduction in plasma
concentration of IL-6, although there was no significant
difference between the two groups. As a consequence, we
speculate that use of low tidal volume and RM may hold
advantages by reducing pulmonary and systemic
inflammatory responses, improving multiple organ failure,
decrease the length of ventilation and reduce mortality.
RM clearly improves oxygenation in some patients with
ARDS, as has been demonstrated in animal models. This
study shows an improvement in oxygenation two hours
after RM on days 1 and 2, which demonstrated RM could
RM can be performed either by sustained inflation,
intermittent sighs, or intermittent high levels of pressure-
controlled ventilation methods.7,16,18,19 The best way to
perform RM remains undetermined. The optimal pressure,
length of time and periodicity may all be important
parameters of RM. The method using high CPAP levels
(40 cmH 2 O for 40 seconds) applied in this study has been
demonstrated to be efficient. In some severe cases,
however, CPAP with 40 cmH 2 O was not enough to open
the collapsed lung units. They need higher pressure and
longer time to get better oxygenation, perhaps with a
better outcome.
It is essential to avoid potential adverse effects on cardiac
3104
Table 5. Comparison of the clinical outcome between the two groups
Outcomes RM group (n=55)
Death in hospital (n (%)) 23 (41.8)
Death by day 28 (n (%)) 16 (29.1)
Death in intensive care unit (n (%)) 18 (32.7)
Survival with unassisted breathing at day 28 (n (%)) 32 (58.2)
Ventilator-free days at day 28 (days, mean±SD) 10.8±10.1
Length of ICU stay (days, mean±SD) 22.5±22.2
Length of hospital stay (days, mean±SD) 43.2±45.6
Organ failure-free days at day 28 (days, mean±SD) 17.4±11.1
Figure 3. The 28-day survival rate between two groups
compared by Kaplan-Meier curve.
output and barotraumas caused by short periods of high
intrathoracic pressures. The previous studies have
demonstrated that there was a low incidence of adverse
effects, moreover these effects were self-limiting and
without apparent long-term sequelae.5,13,14 Although there
was no occurrence of pneumothorax, pneumome-
diastinum, or subcutaneous emphysema, or a
pneumatocele, the patients should be monitored carefully
in the course of RM.
In conclusion, it was safe and useful to increase
oxygenation and it improved the clinical outcome for
ARDS patients ventilated with a low tidal volume and
RMs. In the near future, RM may be the optimal
mechanical ventilation to improve the treatment of ARDS
patients.
Appendix: The participants of the RM Group include: Dr. XI
Xiu-ming (Beijing Fuxing Hospital), Dr. JIANG Li (Beijing Fuxing
Hospital), Dr. ZHU Bo (Beijing Fuxing Hospital), Dr. AN
You-zhong (Peking University People’s Hospital), Dr. LIU Fang
(Peking University People’s Hospital), Dr. WANG Chen (Beijing
Chaoyang Hospital), Dr. ZHAN Qing-yuan (Beijing Chaoyang
Hospital), Dr. ZHOU Jian-xin (Beijing Tiantan Hospital), Dr. QIN
Ying-zhi (Tianjin Third Central Hospital), Dr. ZHANG Na-xin
(Tianjin Third Central Hospital), Dr. WANG Ke-fu (Qilu Hospital
of Shandong University), Dr. CHEN Xiao-mei (Qilu Hospital of
Shandong University), Dr. SUN Yun-bo (Affiliated Hospital of
Qingdao University Medical College), Dr. XING Jin-yan
(Affiliated Hospital of Qingdao University Medical College), Dr.
SONG Qing (General Hospital of Chinese People’s Liberation
Army), Dr. PAN Liang (General Hospital of Chinese People’s
Chin Med J 2010;123(21):3100-3105
Control group (n=55) Relative risk (95% Confidence interval) P values
31 (56.4) 0.74 (0.50–1.10) 0.13
24 (43.6) 0.67 (0.40–1.11) 0.11
29 (52.7) 0.62 (0.39–0.98) 0.03
20 (36.4) 1.60 (1.06–2.42) 0.02
7.4±10.0 0.08
19.8±24.8 0.06
33.2±34.0 0.12
13.0±12.0 0.03
Liberation Army), Dr. LIN Hong-yuan (First Affiliated Hospital of
General Hospital of Chinese People’s Liberation Army), Dr. GUO
Xu-sheng (First Affiliated Hospital of General Hospital of Chinese
People’s Liberation Army), Dr. HU Zhen-jie (Forth Hospital of
Hebei Medical University), Dr. ZHANG Yu-xiang (Forth Hospital
of Hebei Medical University), Dr. XU Yuan (Beijing Tongren
Hospital), Dr. TIAN Zhuo-min (Tianjin People’s Hospital), Dr. JIN
Tao (Tianjin People’s Hospital), Dr. LI Yuan-zhong (Dalian
Municipal Central Hospital), Dr. HAN Shi-quan (Dalian Municipal
Central Hospital), Dr. LIU Liu (Dalian Municipal Central Hospital),
Dr. LI Gang (China-Japan Friendship Hospital), Dr. YI Li
(China-Japan Friendship Hospital)
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(Received March 10, 2010)
Edited by WANG Mou-yue and LIU Huan