Advances in the management of acute respiratory distress syndrome: protective ventilation.

The approach to mechanical ventilation has been revolutionized by new insights into the pathogenesis of respiratory failure in acute respiratory distress syndrome (ARDS). Concepts such as low-volume ventilation, permissive hypercapnia, inverse ratio ventilation, best and intrinsic positive end-expiratory pressure, airway shear, pressure volume curves, inflection points, and prone positioning have radically transformed thinking about ventilator management. Since 1966, more than 8000 ARDS-related publications have appeared. Studies highlighting the experimental basis for innovations in mechanical ventilation are presented. Selected clinical series that exemplify the use of these new strategies are reviewed, to demonstrate how key experimental and clinical research has altered our understanding about what works, and why. Mismanagement of mechanical ventilation causes lung injury and increases mortality. The strategy of protective ventilation has provided the first substantial reduction of mortality in the history of ARDS.