Following on from the positive results in the Tremblay et al. trial [18] , a small study (53 patients) was carried out by Amato et al. in Brazil [20] . The mortality rate was 38% in patients given 'protective' ventilation (PEEP above the lower inflection point on the static pressure-volume curve, tidal volume < 6 ml/kg ideal body weight, driving pressures < 20 cmH 2 O above the PEEP value, permissive hypercapnia, and preferential use of pressurelimited ventilatory modes) compared with 71% in patients on conventional ventilation (P < 0.001). This impressive reduction in mortality was tempered by the higher than normal mortality level in the control group, prompting the National Institutes of Health-funded Acute Respiratory Distress Syndrome Network to set up a similar, larger (861 patients), prospective, multicenter, randomized trial in the US [21] .