Fluid-management strategies in acute lung injury.

To the Editor: The results of the Fluid and Catheter Treatment Trial (FACTT) conducted by the National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network (June 15 issue)1 support a conservative strategy of fluid management in patients with acute lung injury. This strategy should be recognized as only a step in the right direction. The furosemide dosing algorithm in the conservative-strategy group (range, 128 to 167 mg per 24 hours) simply resulted in an even — not negative — net fluid balance, which may have mitigated the potential magnitude of the benefit. Protocol-guided diuretic management, with individualized titration of the dose to achieve a net diuresis, can be readily and safely implemented in the intensive care unit (ICU) and is typically associated with higher doses of furosemide (range, 400 to 440 mg per 24 hours) than those used in FACTT, with the potential for even faster resolution of pulmonary edema.2 The FACTT algorithm should not yet be viewed as “optimal” therapy, but only as an improvement on what heretofore has been considered “conventional” therapy.