From medical treatment option to dogma: Low tidal volume ventilation has become an unquestioned truth in ARDS

Gary Nieman

Abstract

Resistance to paradigm shifts is a common issue in medicine, often delaying the adoption of new therapies despite strong evidence. This perspective explores how medical treatments can transition from being evidence based practices to rigid dogma. Lung-protective ventilation for acute respiratory distress syndrome (ARDS) exemplifies this challenge.

We outline a sequence by which a single influential clinical trial can crystallize into an unquestioned standard of care. The low-tidal-volume ARDSNet strategy, established by a landmark randomized controlled trial (RCT) over twenty-five years ago, exemplifies this process.

Reanalyzing the same data used in the ARDSNet RCT demonstrated that low tidal volume ventilation is not lung-protective in all patient subgroups and may even increase mortality. Despite data clearly demonstrating that the ARDSNet strategy can be harmful and that there has been no reduction in ARDS related mortality over three decades of use, the method remains the standard of care. Indeed, the most recent Guidelines papers published in multiple leading medical journals still strongly recommend low tidal volume for ARDS patients.

This paper argues that the continued dominance of a single paradigm can hinder innovation and delay the adoption of life-saving treatments. Improvements in ARDS management and medicine overall require ongoing reassessment of established practices, openness to new evidence, and the courage to challenge accepted dogma.

Keywords: Medical dogma, Paradigm shifts, Lung protective ventilation, ARDS, VILI, Low tidal volume ventilation, ARDSNet

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