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Lower tidal volumes in Brazil, also in patients without acute respiratory distress syndrome?

In a recent study, Azevedo and colleagues [1] show tidal volumes (VT) to be low in patients in Brazilian ICUs. By showing this, it is clear that ventilation practice in Brazil mirrors worldwide changes, at least with regard to VT in patients with acute respiratory distress syndrome (ARDS) [2, 3].

Efforts to implement protective ventilation have been largely restricted to patients with ARDS, which is understandable since its beneficial effects were convincingly demonstrated in these patients only. It is not unreasonable, however, to consider that lower VT also benefits patients without ARDS [4], although it could also be argued that lower VT strategies could harm patients without ARDS since it may increase sedation and maybe even paralysis needs, which are associated with increased incidence of delirium, ventilator-induced diaphragm dysfunction, and longer duration of ventilation. Furthermore, the new ARDS definition categorizes patients as having mild, moderate and severe ARDS [5]. It has been questioned whether attempts to control VT should be restricted to patients with moderate or severe ARDS. Consequently, the ICU community remains reluctant to use lower VT in patients without ARDS and patients only having mild ARDS, and desires randomized controlled trial (RCT) evidence. When planning a RCT, one would like to know to what VT the 'lower' VT is to be compared.

We would like to know, therefore, what VT was used in patients without ARDS, in patients with mild ARDS, and in patients with moderate or severe ARDS in Brazilian ICUs?

Authors' response

Luciano Cesar Pontes Azevedo, Jorge Ibrain Figueira Salluh, Marcio Soares

We would like to thank Drs Serpa-Neto and Schultz for their interest in our manuscript. We agree with the authors that there is now considerable evidence demonstrating the benefits of lung protective ventilation including lower tidal volumes in patients with ARDS [3] and even for ventilated patients without injured lungs [4]. However, this evidence is not currently translated into daily practice and our study provides additional data suggesting the common use of 'high' tidal volumes for patients with acute respiratory failure and also for the subgroup of those with ARDS [1, 6]. We report (Table 1) data of tidal volumes per predicted body weight in the first day of mechanical ventilation of patients without ARDS, patients with mild ARDS (the previous definition of acute lung injury) and patients with moderate/severe ARDS (the previous ARDS definition before the Berlin definitions). Median tidal volumes in all subgroups were above 6 ml/kg predicted body weight, without statistical difference between subgroups (Kruskall-Wallis test). Reasons for the lack of adherence to this strategy may include concerns about adverse effects of low tidal volumes, such as hypercapnia and increased need for sedatives, insufficient knowledge of the lung protective ventilation protocols and underrecognition of ARDS [7]. In conclusion, we believe more efforts are needed to identify the gaps that result in an incomplete translation of evidence to practice in order to guarantee implementation of the lung protective ventilation strategies on a daily basis.

Table 1 Data on tidal volumes on the first day of ventilatory support for patients without and with ARDS



acute respiratory distress syndrome


randomized controlled trial


tidal volume.


  1. Azevedo LC, Park M, Salluh JI, Rea-Neto A, Souza-Dantas VC, Varaschin P, Oliveira MC, Tierno PF, Dal-Pizzol F, Silva UV, Knibel M, Nassar AP Jr, Alves RA, Ferreira JC, Teixeira C, Rezende V, Martinez A, Luciano PM, Schettino G, Soares M: Clinical outcomes of patients requiring ventilatory support in Brazilian intensive care units: a multicenter, prospective, cohort study. Crit Care 2013, 17: R63. 10.1186/cc12594

    Article  PubMed Central  PubMed  Google Scholar 

  2. Esteban A, Anzueto A, Frutos F, Alía I, Brochard L, Stewart TE, Benito S, Epstein SK, Apezteguía C, Nightingale P, Arroliga AC, Tobin MJ, Mechanical Ventilation International Study Group: Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA 2002, 287: 345-355. 10.1001/jama.287.3.345

    Article  PubMed  Google Scholar 

  3. Villar J, Blanco J, Añón JM, Santos-Bouza A, Blanch L, Ambrós A, Gandía F, Carriedo D, Mosteiro F, Basaldúa S, Fernández RL, Kacmarek RM, ALIEN Network: The ALIEN study: incidence and outcome of acute respiratory distress syndrome in the era of lung protective ventilation. Intensive Care Med 2011, 37: 1932-1941. 10.1007/s00134-011-2380-4

    Article  PubMed  Google Scholar 

  4. Serpa Neto A, Cardoso SO, Manetta JA, Pereira VG, Esposito DC, Pasqualucci Mde O, Damasceno MC, Schultz MJ: Association between use of lungprotective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a metaanalysis. JAMA 2012, 308: 1651-1659. 10.1001/jama.2012.13730

    Article  CAS  PubMed  Google Scholar 

  5. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, Camporota L, Slutsky AS: Acute respiratory distress syndrome: the Berlin Definition. JAMA 2012, 307: 2526-2533.

    Google Scholar 

  6. Linko R, Okkonen M, Pettila V, Perttila J, Parviainen I, Ruokonen E, Tenhunen J, Ala-Kokko T, Varpula T: Acute respiratory failure in intensive care units. FINNALI: a prospective cohort study. Intensive Care Med 2009, 35: 1352-1361. 10.1007/s00134-009-1519-z

    Article  PubMed  Google Scholar 

  7. Cooke CR, Kahn JM, Watkins TR, Hudson LD, Rubenfeld GD: Cost-effectiveness of implementing low-tidal volume ventilation in patients with acute lung injury. Chest 2009, 136: 79-88. 10.1378/chest.08-2123

    Article  PubMed Central  PubMed  Google Scholar 

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Correspondence to Ary Serpa Neto.

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Neto, A.S., Schultz, M.J. Lower tidal volumes in Brazil, also in patients without acute respiratory distress syndrome?. Crit Care 17, 436 (2013).

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