Should the ART trial change our practice?

The optimal level of positive end-expiratory pressure (PEEP) in ARDS has been discussed for more than 50 years (1). The concept of using recruitment maneuvers to open collapsed lung units in association with optimal PEEP was also proposed many years ago (2). A large body of animal studies and small mechanistic studies suggest that the open lung strategy might be beneficial to prevent ventilator-induced lung injury in patients with ARDS. Furthermore, systematic reviews of randomized trials assessing the effect of lung recruitment maneuvers for patients with ARDS suggest that this procedure can decrease mortality without substantial adverse events, however the quality of evidence is low due to risk of bias and variable use of co-interventions (3,4)