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Mechanical ventilation is indispensable for the survival of patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). For optimizing lung recruitment and preventing lung derecruitment there are the following possibilities: first, recruitment manoeuvres may be performed in the most hypoxaemic patients before implementing the preset positive end-expiratory pressure or after episodes of accidental lung derecruitment second, the patient can be turned to the prone position third, closed-circuit endotracheal suctioning is to be preferred to open endotracheal suctioning. To enhance CO 2 elimination when tidal volume is reduced, the following are possible: first, ventilator respiratory frequency can be increased without necessarily generating intrinsic positive end-expiratory pressure second, instrumental dead space can be reduced by replacing the heat and moisture exchanger with a conventional humidifier and third, expiratory washout can be used for replacing the CO 2-laden gas present at end expiration in the instrumental dead space by a fresh gas (this method is still experimental). This bench-to-bedside review presents the scientific rationale for using adjuncts to mechanical ventilation aimed at optimizing lung recruitment and preventing the deleterious consequences of reduced tidal volume. However, excessive tidal volumes and inadequate lung recruitment may contribute to mortality by causing ventilator-induced lung injury. Mechanical ventilation is indispensable for the survival of patients with acute lung injury and acute respiratory distress syndrome.
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