T 

AUT Nycomed GmbH Konstanz, Germany 

References 
1. Esteban A, Ferguson ND, Meade MO, Frutos-Vivar F, Apezteguia C, Brochard L, Raymondos K, Nin N, Hurtado J, Tomicic 
V, et al.; for the VENTILA Group. Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care 
Med 2008;177:170–177. 2. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volume as compared 
with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 
2000;342:1301–1308. 3. Taut FJH, Lo ́pez Rodrıguez A, Tillis W, Yus S, Joensen H, Yaroshetskiy A, Reus V, Gu ̈nther A. 
Global variation in adherence to the ARDS Network ventilation protocol in the VALID study of rSP-C surfactant in severe 
respiratory failure [abstract]. Intensive Care Med 2007;33: S236. 
From the Authors: 
We  agree  with  Drs.  Gu  ̈  nther  and  Taut,  in  their  comments  on  our  article  (1),  that  the  best  way to express tidal volume would 
have  been  as  ml/kg of predicted body weight (BW), but unfortunately, in the first study of mechanical ventilation in 1998 (2), we 
did  not  record  height,  and  were  therefore  unable  to  calculate  predicted  BW.  For  this  reason,  the  comparison  between  the  two 
interna-  tional studies was done with tidal volume expressed as ml/kg of actual BW. The comparison provided in the abstract was 
of  mean  tidal  volume  (ml/kg  actual  BW)  in  the  first  week following a diagnosis of acute respiratory distress syndrome (ARDS). 
In  the  second  international  study  of  mechanical  ventilation,  we  were  able  to  calculate  the  predicted  BW  and,  as  surmised,  the 
tidal  volume  expressed  in  this  fashion  was  higher.  Among  the  4,968  patients  included  in  the  2004  study,  median  (interquartile 
range  [IQR])  recorded  actual  BW  was  75  kg  (64–85),  while  predicted BW (using the ARDSNet formula) was 64 kg (55–71). In 
2004,  the  highest  tidal  volume  recorded  in  the  first  week  after  the  diagnosis  of  ARDS  was  a median of 11 ml/kg predicted BW 
(IQR, 9.5–12) and the lowest tidal volume was a median of 8 ml/kg predicted BW (IQR, 6.5–9). 
Regardless of the availability of predicted BW, we believe that our results do show a convincing decline in administered 
316 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 178 2008 
F 
RIEDEMANN 
tidal  volume  between  1998  and  2004.  It  is  possible  that  out-  comes  would  have  improved  further  in  2004  with  a  greater  tidal 
volume  reduction,  but  this remains speculative. While many would agree that large tidal volumes should be avoided in ARDS, as 
these  authors  are  no  doubt  aware,  strict  adherence  to  a  tidal  volume  of  6  ml/kg  remains  controversial.  In addition, whether it is 
the  tidal  volume  or  the  plateau  pressure  limitation  that  is  most  important  in  limiting ventilator-induced lung injury also remains 
unresolved. As we outlined in the D 
ISCUSSION 
of  our  article  (1),  there  are  numerous  reasons  why  our  study 
did  not  demonstrate  a  statistically  significant  improvement  in  mortality  for  patients  with  ARDS,  only  one  of  which  is  the 
delivered tidal volume in 2004. 
Conflict of Interest Statement: None of the authors has a financial relationship with a commercial entity that has an interest in the 
subject of this manuscript. 
A 
NDRE 
́ 
S 
E 
STEBAN F 
ERNANDO 
F 
RUTOS 
-V 
IVAR Hospital Universitario de Getafe Madrid, Spain 
N 
IALL 
D. F 
ERGUSON University Health Network University of Toronto Toronto, Canada 
A 
NTONIO 
A 
NZUETO South Texas Veterans Health Care System and University of Texas Health Science Center San Antonio, 
Texas 
References 
1. Esteban A, Ferguson ND, Meade MO, Frutos-Vivar F, Apezteguia C, Brochard L, Raymondos K, Nin N, Hurtado J, Tomicic 
V, et al.; for the VENTILA Group. Evolution of mechanical ventilation in re- sponse to clinical research. Am J Respir Crit Care 
Med 2008;177:170– 177. 2. Esteban A, Anzueto A, Frutos F, Alıa I, Brochard L, Stewart TE, Benito S, Epstein SK, Apezteguıa 
C, Nightingale P, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international 
study. JAMA 2002;287:345–355.