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Pressure support for the acute respiratory distress syndrome: less is more.

A consensus regarding a recent improvement of the prognosis of the acute respiratory distress syndrome (ARDS) seems to have emerged recently. Milberg et al. (1) reported in 1995 that the mortality of patients with ARDS in their institution at Seattle had steadily declined from 70% in 1983 to <40% in 1993. Other recent clinical trials reported similar figures (2, 3). Despite some reservations that need to be borne in mind concerning the validity of historical series and the comparability of published trials (4), the trend seems real, at least for certain subgroups of patients. However, when asked which therapeutic advances they believe are responsible for this evolution, the authors are usually unable to identify a single factor. Rather, they propose a list of therapies which, all combined, may have played a role: small tidal volumes, higher levels of positive end-expiratory pressure, inhaled nitric oxide, prone positioning, better control of nosocomial pulmonary infections and of fluid balance, and the use of late corticosteroids (5, 6).