{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,4]],"date-time":"2025-12-04T23:20:52Z","timestamp":1764890452464,"version":"3.46.0"},"reference-count":26,"publisher":"BMJ","issue":"10","license":[{"start":{"date-parts":[[2025,10,29]],"date-time":"2025-10-29T00:00:00Z","timestamp":1761696000000},"content-version":"unspecified","delay-in-days":28,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2025,10,9]]},"published-print":{"date-parts":[[2025,10]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Postoperative pulmonary complications (PPCs) are common after cardiac surgery and are associated with significant morbidity and mortality. Lung-protective ventilation strategies have been proposed to reduce PPCs, but the optimal level of positive end-expiratory pressure (PEEP) and the use of alveolar recruitment manoeuvres (RMs) remain controversial.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods\/analysis<\/jats:title>\n                    <jats:p>In this investigator-initiated, multicentre, open, randomised, parallel-group, superiority clinical trial, elective cardiac surgery patients at risk of PPCs will be assigned to one of two intraoperative ventilation strategies: (1) an open-lung ventilation strategy with protective ventilation, moderate PEEP and RMs or (2) a standard protective ventilation with low PEEP and no RM. The primary outcome will be a composite of prolonged (&gt;24\u2009hour) postoperative mechanical ventilation, reintubation for any cause or hospital-acquired pneumonia within 7\u2009days of surgery, or death within 28 days of surgery. Data will be analysed on an intention-to-treat basis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Ethics and dissemination<\/jats:title>\n                    <jats:p>The VACARM (impact of intraoperatiVe moderAte positive end-expiratory pressure with reCruitment mAnoeuvres versus low positive end-expiRatory pressure on major postoperative pulMonary complications and death after on-pump cardiac surgery in high-risk patients) trial has been approved by an independent ethics committee for all study centres. Recruitment began in July 2021. Results will be published in international peer-reviewed medical journals.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration number<\/jats:title>\n                    <jats:p>\n                      ClinicalTrials.gov\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"clintrialgov\" xlink:href=\"NCT04408495\">NCT04408495<\/jats:ext-link>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-104179","type":"journal-article","created":{"date-parts":[[2025,10,29]],"date-time":"2025-10-29T17:26:02Z","timestamp":1761758762000},"page":"e104179","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Impact of intraoperatiVe moderAte positive end-expiratory pressure with reCruitment mAnoeuvres versus low positive end-expiRatory pressure on major postoperative pulMonary complications and death after on-pump cardiac surgery in high-risk patients: the VACARM randomised clinical trial-study protocol"],"prefix":"10.1136","volume":"15","clinical-trial-number":[{"clinical-trial-number":"nct04408495","registry":"10.18810\/clinical-trials-gov"}],"author":[{"given":"Nathalie","family":"Demaure","sequence":"first","affiliation":[{"name":"Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d\u2019Investigation Clinique de Rennes), Department of Anesthesia and Critical Care, Pontchaillou, Rennes University Hospital, Rennes, Brittany, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jehanne","family":"Le Cunff","sequence":"additional","affiliation":[{"name":"Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d\u2019Investigation Clinique de Rennes), Department of Anesthesia and Critical Care, Pontchaillou, Rennes University Hospital, Rennes, Brittany, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Maryline","family":"Duch\u00eane","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Critical Care, University Hospital Centre Nantes, Nantes, Pays de la Loire, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2226-3982","authenticated-orcid":false,"given":"Bertrand","family":"Rozec","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Critical Care, La\u00ebnnec Hospital, University Hospital of Nantes and Nantes Universit\u00e9, CHU Nantes, CNRS, INSERM, l\u2019institut du thorax, University Hospital Centre Nantes, Nantes, Pays de la Loire, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fabien","family":"Espitalier","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Critical Care, Regional University Hospital Centre Tours, Tours, Centre-Val de Loire, 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Critical Care, University Hospital of Toulouse, Toulouse, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Osama","family":"Abou-Arab","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Critical Care, Amiens-Picardy University Hospital, Amiens, Hauts-de-France, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7019-9727","authenticated-orcid":false,"given":"Pierre-Gr\u00e9goire","family":"Guinot","sequence":"additional","affiliation":[{"name":"Burgundy Franche-Comt\u00e9 University, Besancon, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Pierre","family":"Duval","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Critical Care, University Hospital Centre Rouen, Rouen, Normandy, 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