Goal-Directed Mechanical Ventilation: Are We Aiming at the Right Goals? A Proposal for an Alternative Approach Aiming at Optimal Lung Compliance, Guided by Esophageal Pressure in Acute Respiratory Failure

Table 1

Randomized controlled trials of ARDS ventilation strategies. (last 10 year-humans) years 2000–2012.

Author/year/ref	Mechanical ventilation strategy	Study aims	Major observations
Hodgson et al., 2011, [18]	Recruitment PEEP and PMV	Open-lung strategy titrated PEEP and targeted and low airway pressures	Open-lung strategy was associated with greater amelioration in some systemic cytokines, improved oxygenation, and lung compliance over seven days.
Chung et al., 2010, [19]	HFPV	HFPV and low tidal volume ventilation	Acidosis and hypercapnia induced by VT reduction and increase in PEEP at constant P (plat) were associated with impaired right ventricular function and hemodynamics despite positive effects on oxygenation and alveolar recruitment.
Mekontso Dessap et al., 2009, [20]	Sighs superimposed on lung PMV	Impact of acute hypercapnia and augmented positive	Sighs superimposed on lung-protective mechanical ventilation with optimal PEEP improved oxygenation and static compliance in patients with early ALI/ARDS.
Badet et al., 2009, [21]	Recruitment maneuvers on lung PMV	Comparison of optimal PEEP and recruitment maneuvers, lung-protective mechanical ventilation	Sighs superimposed on lung-protective mechanical ventilation with optimal PEEP improved oxygenation and static compliance.
Mercat et al., 2008, [22]	Recruitment maneuvers	PEEP strategy for setting PEEP	Increasing alveolar recruitment while limiting hyperinflation did not significantly reduce mortality. However, it did improve lung function and reduced the duration of mechanical ventilation and duration of organ failure.
Meade et al., 2008, [23]	PMV with low VT	Strategy using low tidal volumes, recruitment maneuvers	Open lung resulted in no significant difference in all-cause hospital mortality and high PEEP or barotrauma compared with an established low-tidal-volume protocoled ventilation strategy.
Wolthuis et al., 2008, [24]	Low VT and PMV	Lower Tv and PEEP prevent pulmonary inflammation in patients without preexisting ALI	Lower VT and PEEP may limit pulmonary inflammation.
Pachl et al., 2006, [25]	HFOV	Normocapneic HFOV affects differently extra pulmonary and pulmonary forms of ARDS	HFOV recruits and thus it is more effective in ARDS.

ALI: acute lung injury, ARDS: acute respiratory distress syndrome, HFOV: High-frequency oscillatory ventilation, HFPV: high-frequency pulmonary ventilation, P (plat): Plateau pressure, PEEP: positive end expiratory pressure, PMV: protective mechanical ventilation, and VT: tidal volume.