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I'm impressed that I can even spell Manoeuvers... In September 2010, Critical Care and Resuscitation published a small randomised controlled trial examining the pulmonary and non-pulmonary effects of recruitment manoeuvers. It could not demonstrate an improvement in mortality, found that oxygenation benefits were minimal and transient, and that significant, though reversible, haemodynamic effects were common. I can remember countless patients who I have managed over the years who appear to have benefited from such an intervention. While I'm well aware of the potential consequences, I can't escape the fact that hypoxia is bad for you, and ventilating patients on 100% oxygen and 15 PEEP doesn't give you a lot of leeway. We now understand the negative effects of ventilation in ARDS better than ever before, and this has led to protective lung ventilation strategies. However, ventilating patients on small tidal volumes, albeit with higher PEEPs than we used to, surely must lead to increasing atelectasis (with consequent sheer trauma) and worsening gas exchange The questions then are : 1  are they worth it, and if so, 2  which manoeuver is the best Unfortunately the largest RCT and 2 meta-analyses have concluded that there is little mortality benefit to be gained from Recruitment Manoeuvers, though the systematic reviews did show transiently improved oxygenation. The disadvantages of recruitment maneuvers are numerous  potential major barotrauma, significant haemodynamic compromise, patient discomfort  which certainly raises the issue of cost-benefit. Personally I've used a 40cmH20 for 40 seconds approach and have seen significant benefits. It appears relatively well tolerated overall, and so far I've never seen a major complication. But this is ABM (anecdote base medicine). Recent publications from the Alfred in Melbourne have described the "Staircase manoeuver" in which a stepwise increase in PEEP, maintaining a tidal pressure control ventilation, gradually increases lung pressures to maximums of 55-60cmH20. Their results so far have been impressive, but more rigorous examination of this procedure is required.