Please select the eligibility criteria that correspond to the clinical trial below.
Title: Randomized Controlled Trial of Maximum Alveolar Recruitment Maneuver Plus Titrated PEEP Versus ARDSNet Strategy for ARDS
Brief Summary: Acute respiratory distress syndrome (ARDS) is a common scenario in intensive care unit. Discussions about it is exponentially growing up due its high mortality rates all over the world and low quality of life among survivors. Mechanical ventilation is recognized to play an important role in treatment of patients with ARDS. However, mechanical ventilation itself has the potential to produce or worsen alveolar injury if inadequate strategies are chosen. Several studies compared different mechanical ventilation strategies in ARDS but the results remain uncertain regarding their influence on survival in patients with ARDS. Thus, this is a multicentric randomized controlled trial, with allocation concealment and intention to treat analysis to investigate if maximum alveolar recruitment maneuver in association to Positive end-expiratory pressure (PEEP) titrated by static compliance of respiratory system (ART strategy) is able to increase 28 days survival in patients with moderate to severe ARDS compared to conventional strategy proposed by the ARDS Clinical Network (ARDSNet strategy). Patients considered to this trial are those in mechanical ventilation with diagnosis of moderate to severe ARDS less than 72hours. Patients included will be randomized to receive ART strategy or ARDSNet strategy and will be followed until hospital discharge, 28 days and 6 months.


Options:
A: Inclusion Criteria:

Adult ICU patients who met all of the following criteria:

* Currently intubated and receiving mechanical ventilation
* Within 72 Hours of a diagnosis of ARDS (moderate and severe) based on the following Berlin definition:
* Within 1 week of a known clinical insult or new or worsening respiratory symptoms
* Bilateral opacities on chest x-ray (CXR) which are not fully explained by effusions, lobar/lung collapse or nodules
* Respiratory failure not fully explained by cardiac failure or fluid overload
* Arterial oxygen pressure (PaO2)/FiO2 \< 200mmHg with PEEP ≥ 5cmH2O

Exclusion Criteria:

* \> 72 hours since diagnosis of ARDS
* \> 10 days of continuous mechanical ventilation
* Barotrauma (pneumothorax, pneumomediastinum, subcutaneous emphysema or any intercostal catheter for the treatment of air leak)
* Significant chest trauma i.e. multiple rib fractures
* Active bronchospasm or a history of significant chronic obstructive pulmonary disease or asthma
* Clinical suspicion for significant restrictive lung disease (history of pulmonary fibrosis or suggestive pulmonary function tests)
* Moderate or severe traumatic brain injury, the presence of an intracranial pressure monitor, or any medical condition associated with a clinical suspicion of raised intracranial pressure
* Unstable cardiovascular status defined as sustained heart rate \< 40 or \> 140 bpm, ventricular tachycardia, or SBP \< 80mmHg
* Pregnancy
* Receiving ECMO
* Receiving high frequency oscillatory ventilation
* Death is deemed imminent and inevitable
* The treating physician believes it is not in the best interest of the patient to be enrolled in the trial
* Consent not obtained or refused by patient's legal surrogate
B: Inclusion Criteria:

* Man or female older than 18 years
* ARDS since less than 12 hours
* PaO2 / FiO2 \< 200 avec une PEEP ≥ 5 (Berlin Moderate or severe)

Exclusion Criteria:

* brain injury with high ICP
* BMT Liver Cirrhosis Child C Pregnancy Burns Morbid obese patients (BMI \> 40) Moribund
C: Inclusion Criteria:

1. Adult patients aged 18 years or more, both gender
2. Receiving endotracheal intubation and mechanical ventilation for less than 36 hours
3. Presenting with a Severe ARDS :

   * Acute onset
   * PaO2/FiO2 ≤ 200 (≤ 26.7 kPa)
   * Bilateral pulmonary infiltrates on frontal chest radiography
   * Capillary wedge pressure \< 18 mm Hg if measured or no evidence for left atrial hypertension
4. During since 12-24 hours
5. AND with severity criteria : PaO2/FiO2 \< 150 mm Hg (\< 20 kPa) under FiO2 ≥ 0.6, PEEP ≥ 5 cm H2O and a tidal volume equal to 6 ml/kg PBW.
6. Written consent from patient's next of kin

Exclusion Criteria:

1. contra-indication to the prone position

   * Intracranial pressure \> 30 mm Hg or cerebral perfusion pressure \< 60 mm Hg
   * Massive haemoptysis needing urgent surgical or radiological treatment
   * Tracheal or thoracic surgery in the last 15 days
   * Facial trauma or surgery in the last 15 days
   * Deep venous thrombosis or pulmonary embolism treated in the last 2 days
   * Cardiac pace maker implantation in the last 2 days
   * Unstable bone dislocations of rachis, femur, rib cage, pelvis
   * Mean systolic arterial pressure less than 70 mm Hg despite vasopressive therapy
   * Pregnancy
   * Bronchopleural fistula treated with a single anterior chest tube (risk of kinking in prone position)
2. Exclusion criteria for respiratory raisons

   * Necessity to use NOi or almitrine
   * Extra body circulation for oxygenation and/or CO2 epuration
3. Exclusion criteria linked to clinical context

   * Pulmonary transplantation
   * Burns ≥ 20% of body surface
   * Chronic respiratory insufficiency under home oxygen therapy or non invasive ventilation
   * Chronic disease supposed to be fatal in less than 1 year
   * Non invasive ventilation for more than 24 hours before enrollment
4. Other exclusion criteria

   * Decision to stop life-supportive therapies before enrollment
   * Enrollment in an other trial testing an intervention and with mortality as primary end point in the last 30 days
   * Prior enrollment in the same study
   * Prone position before enrollment
D: Inclusion Criteria:

* intubated, mechanically ventilated patients with diagnosis of moderate to severe ARDS less than 72 hours

Exclusion Criteria:

* age less than 18 years
* use of vasopressor drugs in increasing doses over the last 2 hours or mean arterial blood pressure less than 65mmHg
* presence of any contraindication to hypercapnia as intracranial hypertension or acute coronary syndrome
* pneumothorax, pneumomediastinum, subcutaneous emphysema or pneumatocele
* patient with no therapeutic perspective, candidates for palliative care exclusively
* patient previously randomized in the ART

Answer: D