[

Original Research Critical Care Medicine

Standardizing Predicted Body Weight Equations for

Mechanical Ventilation Tidal Volume Settings
Olinto Linares-Perdomo, PhD; Thomas D. East, PhD; Roy Brower, MD; and Alan H. Morris, MD

Recent recommendations for lung protective mechanical ventilation include a

tidal volume target of 6 mL/kg predicted body weight (PBW). Different PBW equations might
introduce important differences in tidal volumes delivered to research subjects and patients.

BACKGROUND:

PBW equations use height, age, and sex as input variables. We compared National
Institutes of Health (NIH) ARDS Network (ARDSNet), actuarial table (ACTUARIAL), and
Stewart (STEWART) PBW equations used in clinical trials, across physiologic ranges for age
and height. We used three-dimensional and two-dimensional surface analysis to compare
these PBW equations. We then used age and height from actual clinical trial subjects to quantify PBW equation differences.

METHODS:

Significant potential differences existed between these PBW predictions. The

ACTUARIAL and ARDSNet surfaces for women were the only surfaces that intersected
and produced both positive and negative differences. Mathematical differences between
PBW equations at limits of height and age exceeded 30% in women and 24% in men for
ACTUARIAL vs ARDSNet and about 25% for women and 15% for men for STEWART
vs ARDSNet. The largest mathematical differences were present in older, shorter subjects,
especially women. Actual differences for clinical trial subjects were as high as 15% for men and
24% for women.

RESULTS:

Significant differences between PBW equations for both men and women
could be important sources of interstudy variation. Studies should adopt a standard PBW
equation. We recommend using the NIH National Heart, Lung, and Blood Institute ARDS
Network PBW equation because it is associated with the clinical trial that identified 6 mL/kg
PBW as an appropriate target.
CHEST 2015; 148(1):73-78
CONCLUSIONS:

Manuscript received November 17, 2014; revision accepted February

10, 2015; originally published Online First March 5, 2015.
ABBREVIATIONS: ALI 5 acute lung injury; ARDSNet 5 ARDS Network;
MV 5 mechanical ventilation; NIH/NHLBI 5 National Institutes of
Health/National Heart, Lung, and Blood Institute; PBW 5 predicted
body weight; Vt 5 tidal volume; Vtset 5 tidal volume set
AFFILIATIONS: From the Pulmonary and Critical Care Division
(Drs Linares-Perdomo and Morris), Department of Medicine, Intermountain Medical Center, Salt Lake City, UT; LCF Research (Dr East),
New Mexico Health Information Collaborative, Albuquerque, NM;
Pulmonary and Critical Care Medicine (Dr Brower), Johns Hopkins
University School of Medicine, Baltimore, MD; and the University of
Utah School of Medicine (Dr Morris), Salt Lake City, UT.

This work was supported by Agency for

Healthcare Research & Quality [Grant HS06594], Siemens Inc, Emtek
Inc, ACT/PC Inc, the Respiratory Distress Syndrome Foundation, the
Deseret Foundation (LDS Hospital), and Intermountain Healthcare.
CORRESPONDENCE TO: Olinto Linares-Perdomo, PhD, Pulmonary/
Critical Care Division, Sorenson Heart & Lung Center6th Floor,
Intermountain Medical Center, 5121 S Cottonwood St, Murray,
UT 84157-7000; e-mail: Olinto.linares@imail.org
2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of
this article is prohibited without written permission from the American
College of Chest Physicians. See online for more details.
DOI: 10.1378/chest.14-2843
FUNDING/SUPPORT:

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73

Mechanical ventilation (MV) strategies for acute lung

injury (ALI) and patients with ARDS can have different risks and benefits.1-3 Evidence from experimental
models has demonstrated ventilator-induced lung injury
from excessive volumes and pressures during inspiration and from low volumes and pressures during expiration.2 Many MV modes require a tidal volume setting
(Vtset). Predicted body weight (PBW), rather than
actual body weight, reflects lung size and is commonly
used to estimate required tidal volume (Vt), because
actual body weight could produce excessive Vt in obese
patients or inadequate Vt in underweight patients.
Although MV strategies comparing different Vt in
patients with ALI/ARDS yielded inconsistent results,
the best current evidence and practice emphasize lung
protective MV with a Vt target of 6 mL/kg PBW in
TABLE 1

patients with ALI/ARDS.3-7 While we have no evidence

that variation in PBW has an important influence on
patient outcome, it seems reasonable to standardize
PBW estimation to remove its potential impact on
outcome.
Several clinical trials used different equations for estimating the PBW required for calculating Vt. While
FOR EDITORIAL COMMENT SEE PAGE 3

some investigators used different terms (eg, ideal body

weight), we will refer to all predictions as PBW predictions. Stewart et al6 calculated PBW 5 25 3 (height
in meters)2. Brochard et al8 calculated PBW 5 actual
body weight 2 estimated weight gain due to water

] PBW Equations and Results in Different Clinical Trials

Clinical Trial

PBW Equation

Stewart et al6 (T. Stewart, MD,

personal communication, 2013)

Higher VT Group,
mean SD

STEWART equation

Lower VT Group,
mean SD

10.8 1.0

7.2 0.8

10.3 1.7

7.1 1.3

10.2 0.1

7.3 0.1

Men and women: 25 3 (height in m)2

Brochard et al

Men and women

Actual body weight 2 estimated weight
gain due to water and salt retention

Brower et al9 and Knoben et al10

ARDSNet equation
Men: 50.0 1 0.905 3 ([height in cm] 2 152.4)
Women: 45.5 1 0.905 3 ([height in cm] 2 152.4)

Morris et al14 and Society of

Actuaries and Association of
Life Insurance Medical
Directories of America15

ACTUARIAL equation

7.7 , 0.1a

Men: 24.881 3 (height in m)2 1 0.0957 3 age

(y) 2 3.508
Women: 19.347 3 (height in m)2 1 0.1885 3 age
(y) 2 2.2575
Society of Actuaries and
Association of Life Insurance
Medical Directories of America15
and East et al16, b

ACTUARIAL equation

10.2 3b

7.6 1.7b

11.8 0.8

6.2 0.8

Men: 24.881 3 (height in m)2 1 0.0957 3 age

(y) 2 3.508
Women: 19.347 3 (height in m)2 1 0.1885 3 age
(y) 2 2.2575
NIH/NHLBI ARDSNet4 and
Knoben et al10

ARDSNet equation
Men: 50.0 1 0.905 3 ([height in cm] 2 152.4)
Women: 45.5 1 0.905 3 ([height in cm] 2 152.4)

ARDSNet 5 ARDS Network; NIH/NHLBI 5 National Institutes of Health National Heart, Lung, and Blood Institute; PBW 5 predicted body weight; VT 5 tidal
volume.
aControl group only (extracorporeal group subjects ignored).
bOnly for the 179 patients supported with the assist/control mechanical ventilation mode.

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and salt retention. Brower et al9 calculated PBW 5

50.0 1 0.905 3 (height in cm 2 152.4) for men and
45.5 1 0.905 3 (height in cm 2 152.4) for women.10 The
PBW equations used by Brower et al9 used equations
from Devine,11 supported by subsequent publications.12,13
Morris et al14 calculated PBW (from actuarial tables)
as 24.881 3 (height in meters)2 1 0.0957 3 (age in
years) 2 3.508 for men and as 19.347 3 (height in
meters)2 1 0.1885 3 (age in years) 2 2.2575 for women.14,15
East et al16 used the same PBW equations as Morris et al.14
The National Institutes of Health/National Heart, Lung, and
Blood Institute (NIH/NHLBI) ARDS Network (ARDSNet)4

Materials and Methods

PBW Mathematical Equations
We compared three PBW equations, ACTUARIAL, STEWART, and
ARDSNet (Table 1), to evaluate the mathematical differences between
them within all possible combinations of height and age for both sexes
(Fig 1). We varied height from 152.4 to 210 cm because this range
includes most adult patients with ARDS. We included ages from 18 to
98 years. We produced three-dimensional surfaces of PBW as a function of age and height using Matlab, version R12 (The MathWorks Inc).
To quantify the difference between the surfaces produced by two PBW
equations, we expressed the differences (Fig 2) as a percent of the average PBW (since neither of the surfaces can be considered a more valid
representation)17 according to the following equations:

Results
Mathematical Results

ACTUARIAL vs ARDSNet: In women, these prediction

equation surfaces intersect (Fig 1A) but not in men
(Fig 1B). Differences for women (Fig 2A) were maximum
between young and tall women and old and short women.
%PBW difference varied from about 211.8% to about
30% for women (Figs 1A, 2A). In men, the ARDSNet

used the same PBW equations as Brower et al.9 The PBW

equations used in these trials, and Vt in the experimental groups, are summarized in Table 1. There is currently no standard for calculating PBW.
We examined the magnitude of the deviations in
PBW from the NIH/NHLBI ARDSNet10 equation with
two different PBW equations: from actuarial tables
(ACTUARIAL)15 and Stewart et al6 (STEWART). We
used actual clinical trial subject data16 to assess the
magnitude of differences of PBW equations on Vtset
in a clinical trial cohort.
ACTUARIAL 2 ARDSNet

3 100% eq 1
%PBW difference 5
0.5 ACTUARIAL 1 ARDSNet

STEWART 2 ARDSNet

%PBW difference 5
3 100%
0.5 STEWART 1 ARDSNet

eq 2

PBW Dierences in Clinical Trial Subjects

We collected data from 179 subjects ventilated with an assist/control mode
in a multicenter, randomized clinical trial (115 men and 64 women)
(Table 2).16 We generated two-dimensional plots of %PBW difference
as a function of age and height for women and men (Fig 3).

PBW equations are consistently lower than ACTUARIAL

PBW equations for all combinations of age and height
(Fig 1B). The maximum %PBW difference occurs in
older and shorter men (Fig 2B). %PBW difference varied from about 5% to about 24% (Figs 1B, 2B).
STEWART vs ARDSNet: In women and men, the
ARDSNet predictions were consistently lower than
STEWART predictions for all heights (Figs 1C, 1D). The

Figure 1 A-D, ACTUARIAL,14,15

STEWART,6 and ARDSNet4,10 PBW
equation surfaces for women and
men. A, B, Mathematically derived
surface of PBW as a function of age
(18-98 y) and height (152.4-210 cm)
for ACTUARIAL and ARDSNet.
C, D, Mathematically derived surface of PBW as a function of age
(18-98 y) and height (152.4-210 cm)
for STEWART and ARDSNet.
ARDSNet 5 ARDS Network; PBW 5
predicted body weight.

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75

Figure 2 A-D, %PBW difference for

women and men. A, B, ACTUARIAL 2
ARDSNet. C, D, STEWART 2
ARDSNet. STEWART PBW predictions are age independent. See
Figure 1 legend for expansion of
other abbreviations.

surface-plot differences reveal maximum PBW prediction equation differences in young and short women.
The %PBW difference varied from about 12% to about
25% in women and about 7.5 to about 15% in men
(Figs 1C, 1D, 2C, 2D).
Clinical Trial Subject Results

The clinical trial subjects16 had maximum

(ACTUARIAL 2 ARDSNet) %PBW differences (Figs 3A-D)
between about 210% and about 24% for women and about
5% and about 16% for men. For example, an 80-year-old
woman, 152.4 cm tall, had a PBW difference of about 24%,
and a 20-year-old, 183 cm tall, woman had a %PBW difference of about 210% (Figs 3A, 3B). For (STEWART 2
ARDSNet), the maximum %PBW differences were between
about 25% and about 15% for women, and between
about 13% and about 7% PBW for men (Figs 3A-D).

Discussion
The PBW differences from ARDSNet predictions for the
ACTUARIAL and STEWART predictions (Figs 1-3)
could be clinically significant, although our study does
TABLE 2

not provide proof of this. However, we see no reason to

continue to introduce variation in PBW calculations.
Our results indicate that PBW calculation differences
could be as high as about 30%. We do not know that
these differences produce important changes in patient
outcome, but we think continuing to allow this PBW
variation is unwise.
These PBW differences will create unwarranted variation
in the mechanical ventilator Vtset in different studies
and in clinical practice. The PBW differences may contribute significantly to the inconsistent results from different MV clinical trials in patients with ALI/ARDS.
Standardization of PBW for both clinical research and
clinical practice seems the only reasonable response to
the results we present. The ARDSNet PBW equations
seem a reasonable choice, since the NIH/NHLBI
ARDSNet study provided the results that have become a
common clinical target for Vtset.4 The ARDSNet PBW
equations are not new. They were first introduced by
Devine11 and limited to patients 152.4 cm (5 ft) or taller,
although they appear to be applicable to shorter adults.18

] Demographic Data of Clinical Trial Subjects 152.4 cm (5 ft) Tall, Supported With Assist/Controlled
Mechanical Ventilation

Characteristic
Subjects, No.
Height, cm

Men
115

64

176.8 (7.5, 157.5-198.1)

Age, y

45.1 (16.5, 17-86)

Measured weight, kg

86.9 (19.4, 45-169)

VT settings, No.

Women

162.6 (6.9, 152-183)

44.23 (18.1, 16-85)
76.6 (23.7, 40-182.3)

24,561

13,661

Data presented as mean ( SD, range) unless otherwise indicated. See Table 1 legend for expansion of abbreviation.

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Figure 3 A-D, The %PBW differences from ARDSNet predictions (for

the ACTUARIAL1 and STEWART2
predictions) for clinical trial subject
data as a function of age and height
for women and men.16 See Materials
and Methods section for equations.
See Figure 1 legend for expansion of
other abbreviations.

While it is not possible to identify a true or correct

PBW, it is possible to choose a reasonable PBW equation
that will eliminate this source of unwarranted variation
in clinical research and practice. This will stabilize the
choice of Vtset and likely improve results in both clinical research and practice, just as stabilization of process
has improved products in industry.19

Acknowledgments
Author contributions: O. L.-P., T. D. E.,
R. B., and A. H. M. had full access to all of the
data in the study and take responsibility for
the integrity of the data and the accuracy
of the data analysis. O. L.-P., T. D. E., and
A. H. M contributed to the study concept
and design; T. D. E. and A. H. M. contributed
to data acquisition; O. L.-P., R. B., and A. H. M.
contributed to data analysis and interpretation; O. L.-P. and A. H. M. contributed to
writing the manuscript; O. L.-P., T. D. E.,
R. B., and A. H. M. contributed to revision of
the manuscript and approved the final version
Financial/nonfinancial disclosures: The
authors have reported to CHEST that no
potential conflicts of interest exist with any
companies/organizations whose products or
services may be discussed in this article.
Role of sponsors: The sponsors had no role
in the design of the study, the collection and
analysis of the data, or in the preparation of
the manuscript.
Other contributions: See Reference 16 for
collaborating institutions and personnel in the
clinical trial from which we extracted data.

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Conclusions
Significant differences between PBW equations for men
and women could be important sources of interstudy
variation. Studies should adopt a standard PBW equation.
We recommend using the NIH/NHLBI ARDSNet PBW
equation because it is associated with the clinical trial that
identified 6 mL/kg PBW as an appropriate Vtset target.

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