Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome Publicado en @NEJM el https://t.co/acCeO27rnM
Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.
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Mar 2019 – Oct 2025Where it's discussed
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The discussions demonstrate a collective recognition of the landmark 2000 ARDSNet trial and subsequent research emphasizing lower tidal volumes, with posts describing it as a 'paradigm shift' and 'most important study' in critical care. The tone is respectful and enthusiastic, citing specific trials and clinical practices, indicating that the publication has profoundly impacted both knowledge and patient management approaches in respiratory medicine.
Most discussions strongly support the significance of lower tidal volume strategies based on foundational studies like the ARDSNet trial.
Posts express high interest by referencing historical and recent research, emphasizing the importance of this ventilation approach.
Many posts delve into methodological details, historical context, and clinical implications, reflecting deep engagement.
The discussions highlight the transformative influence of the study on intensive care practices and patient outcomes worldwide.
Abstract in brief
- A clinical trial compared traditional ventilation with higher tidal volumes (10-15 ml/kg) to lower tidal volumes (6 ml/kg) in patients with acute lung injury and ARDS, finding that lower tidal volumes reduced mortality and increased days off ventilator.
- The study was stopped early because patients receiving lower tidal volumes had a significantly lower death rate (31% vs. 39.8%) and spent more days breathing without assistance, indicating better outcomes with gentler ventilation.
- Results showed that lower tidal volume treatment resulted in lower plateau pressures and less lung stretch, suggesting that minimizing lung injury during ventilation improves survival in these patients.]
Top posts
Most liked on X and Bluesky2/Covid causes ARDS. The cornerstone of ARDS management is lung protective ventilation → reduce mechanical stress on the lung → minimize ventilator-induced lung injury. The landmark ARMA trial showed lower tidal volume ventilation helps in this effort https://t.co/MBybOQJC6K
A short history of ventilation in ARDS: in 2000 ARDSNET published landmark study showing tidal volumes of 6ml/kg better than 12ml/kg for mortality and ventilator days. Been proven again. #FOAMcovid https://t.co/VxK4vPV9bs
Hoy volví a hablar de investigación, en el taller de lectura crítica de artículos científicos para los nuevos residentes, me encanta. Iniciamos con un clásico. https://t.co/b6euMDoIXT
Thanks for reading! References: 1. https://t.co/gLluaxsHyI 2. https://t.co/exupaPT7Hz 3. https://t.co/UF3lV3jdt5 4. https://t.co/us3T9b0RKM
From the #NEJMArchive: Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome (May 4, 2000) https://t.co/WppIJ8uUJH https://t.co/ccXFKBjvZl
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TV/PBWが6-8mL/kgという考え方はそもそも2000年のARMAstudy周辺から始まった概念でした。しかし実肺容量から外れる事も多く、標準化にはPFVCがいいかもしれない?という発想から今回の研究は行われてますhttps://t.co/8ftopmZJ7f PFVCは身長、性別に加えて年齢と人種も利用https://t.co/WhF9ajyAsG
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
RT @DiegoEscarraman: Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation…
Top 3 estudios que nos han enseñado a titular mejor el volumen tidal #AventhoAnestesia #AVENTHO #SMMCE ❶ Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome Publicado en @NEJM el https://t.co/acCeO27rnM
Winner of the
Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome | NEJM https://t.co/glGFMfgz03
@nickmmark ARMA of cors https://t.co/b9o4aJQrf7
2) Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome (https://t.co/OvSbLQy52n)
@giovannilandoni @germ_red @BJAJournals 2/ Clinicians once adjusted blood gas values through aggressive ventilation for short-term perfection. #Protectiveventilation taught us to consider the long-term impact. https://t.co/GHXd38Nynt https://t.co/XvE2VWuLne
@stefankmil https://t.co/CZT0NlT0Qd
@TracyBethHoeg @Timothee_MD @VPrasadMDMPH Yes. ARMA study control arm protocol was well beneath standard of care at the time as practiced by intensivists who took a pragmatic approach to tidal volumes and peak/plateau pressures in pts w poor lung compliance. Excellent discussion by Deans, et al. https://t.co/9XzUSae475
@SteveBigpond @delton @kevinnbass You are a fucking idiot, NIV in no way controls for tidal volume , thereby negating the greatest advancement in ARDS management. https://t.co/i2RLPRI0XK
RT @PharmacyToDose: #TrialOfTheDay for May 5th is the ARDSNet Trial. One of the biggest reductions of mortality in the critical care lite…
RT @PharmacyToDose: #TrialOfTheDay for May 5th is the ARDSNet Trial. One of the biggest reductions of mortality in the critical care lite…
#TrialOfTheDay for May 5th is the ARDSNet Trial. One of the biggest reductions of mortality in the critical care literature and we still use this ventilation strategy today. Link: https://t.co/lIROMNfdOc #PharmICU #TwitteRX #ARDS #PulmTwitter #MedEd #SoMe #FOAMed https://t.co/LwmCrYixPX
RT @IM_Crit_: Thanks for reading! References: 1. https://t.co/gLluaxsHyI 2. https://t.co/exupaPT7Hz 3. https://t.co/UF3lV3jdt5 4. https://…
RT @IM_Crit_: Thanks for reading! References: 1. https://t.co/gLluaxsHyI 2. https://t.co/exupaPT7Hz 3. https://t.co/UF3lV3jdt5 4. https://…
Thanks for reading! References: 1. https://pubmed.ncbi.nlm.nih.gov/10793162/ 2. https://pubmed.ncbi.nlm.nih.gov/15616401/ 3. https://pubmed.ncbi.nlm.nih.gov/12406836/ 4. https://pubmed.ncbi.nlm.nih.gov/21742211/
Thanks for reading! References: 1. https://t.co/gLluaxsHyI 2. https://t.co/exupaPT7Hz 3. https://t.co/UF3lV3jdt5 4. https://t.co/us3T9b0RKM
https://t.co/3z3uwdYoQT
@anujtiwari11 Have to quote Dr Tobin’s work in there 1. https://t.co/pMNlQ9cbtH
@korin_sheep 一回換気量6mL/kgと12mL/kgを比較した際に一回換気量6mL/kgのほうが生存率が高い。(図1) →低一回換気量が良いとされた。 https://t.co/2N8yrwbUpe
@MikeAlbanese @VBrisingr @No_I_Am_Gary @kevinmcashman https://t.co/2OfauPmCyv as i said, traditional ventilation use was killing people (not all obv, but acutely injured people absolutely). changing standards of use and lowering the intubation-craze that was an early idea has objectively saved lives.
See full trial at: https://t.co/LEwLqPMNz5
El estudio clásico es el ARDSnet: AKA Con el volumen tidal (como con muchas otras cosas). Menos es más. https://t.co/JvTHf58jZk
RT @JulesBass6: Hard to believe that this was published 21 years ago! Still one of the most important studies in #CriticalCare. This was on…
Hard to believe that this was published 21 years ago! Still one of the most important studies in #CriticalCare. This was only possible because the @nih_nhlbi had the foresight to establish the #ARDSNetwork. Wish we had a #Sepsis network! https://t.co/xM1QgKKurf
https://t.co/cvFwX7q6Rx
Tacking this beast for journal club this week. The paradigm shifting work from ARDS Net which was published *almost* 21 years ago to the day. No regrets choosing this although it has taken me four working days to read... https://t.co/QOIKorSW0D https://t.co/r32iSKTpX6
@Matanuki "Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome" https://t.co/BQEqIvgTBA #ARDS 2001年。 "CONCLUSIONS : In patients with ALI/ARDS , mechanical ventilation with a lower(ry
La importancia de utilizar 6-8 ml/kg de peso predicho: Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome | NEJM https://t.co/iLGKaU8aMw
RT @iAMDrBrightside: Hoy volví a hablar de investigación, en el taller de lectura crítica de artículos científicos para los nuevos resident…
Hoy volví a hablar de investigación, en el taller de lectura crítica de artículos científicos para los nuevos residentes, me encanta. Iniciamos con un clásico. https://t.co/b6euMDoIXT
After his study, other groups published the same strategy but did not have the same findings. Finally, in 2000, ARDS Net, a multicentric and large trial confirmed his findings. + https://t.co/URuFkzbAfa
@WesElyMD @NidaQadirMD @efan75 @gsmartinmd @SCCM @Paul_Wischmeyer @drdangayach @laxswamy @nickmmark @PulmCrit This is interesting and it is a lovely read however that’s not why we use 6ml/kg for tidal volume. It is because of this large multicenter, parallel-group, randomized controlled trial https://t.co/PwiBHLsTqY
RT @david_furfaro: 2/Covid causes ARDS. The cornerstone of ARDS management is lung protective ventilation → reduce mechanical stress on the…
RT @andymoz78: Indeed PROSEVA, a trial of proning in ARDS, demonstrated a 16.8% ARR https://t.co/EwFu8uLEuD Low tidal volumes -the most ro…
Indeed PROSEVA, a trial of proning in ARDS, demonstrated a 16.8% ARR https://t.co/EwFu8uLEuD Low tidal volumes -the most robustly reproduced effect in ARDS – had an 8.8% ARR https://t.co/wj78yzDB1a
ARDS: (ARMA, PROSEVA, ACURASYS, CESAR, EOLIA, PETAL, Driving pressure and survival in ARDS “Amato”) https://t.co/16frvqt8Jn https://t.co/FLh9EHObEJ https://t.co/05mL2FVEmn https://t.co/JQFeswX7UY https://t.co/shEH9PkmHX https://t.co/NhpXPZudoQ https://t.co/XhzT5fvLcA
otro objetivo de "oxigenación" que es el mismo que el del ARDSnet https://t.co/S6WBPHn70k
RT @jopo899: A short history of ventilation in ARDS: in 2000 ARDSNET published landmark study showing tidal volumes of 6ml/kg better than 1…
RT @jopo899: A short history of ventilation in ARDS: in 2000 ARDSNET published landmark study showing tidal volumes of 6ml/kg better than 1…
RT @jopo899: A short history of ventilation in ARDS: in 2000 ARDSNET published landmark study showing tidal volumes of 6ml/kg better than 1…
RT @jopo899: A short history of ventilation in ARDS: in 2000 ARDSNET published landmark study showing tidal volumes of 6ml/kg better than 1…
RT @jopo899: A short history of ventilation in ARDS: in 2000 ARDSNET published landmark study showing tidal volumes of 6ml/kg better than 1…
RT @jopo899: A short history of ventilation in ARDS: in 2000 ARDSNET published landmark study showing tidal volumes of 6ml/kg better than 1…
A short history of ventilation in ARDS: in 2000 ARDSNET published landmark study showing tidal volumes of 6ml/kg better than 12ml/kg for mortality and ventilator days. Been proven again. #FOAMcovid https://t.co/VxK4vPV9bs
Mainstays of acute respiratory distress syndrome (ARDS) management include: 1⃣Low tidal volume ventilation - lowers mortality, compared to larger "traditional" tidal volumes, as shown in the ARMA trial (2000): https://t.co/zcIIVcqQc9 https://t.co/tnRe7TXaMe
RT @precordialthump: @SonoRambler @emcrit @cliffreid @airwaycam @PulmCrit @OttestadWilliam @CriticalCareNow @cameronks In ARDSNet ARMA tria…
@SonoRambler @emcrit @cliffreid @airwaycam @PulmCrit @OttestadWilliam @CriticalCareNow @cameronks In ARDSNet ARMA trial baseline minute ventilation was about 13 L/min. Even in the low tidal volume group PCO2 was 40 with a std deviation of 10 over first 7 days. So some had very low PCO2 for some reason... https://t.co/JoCgArlVxJ
RT @david_furfaro: 2/Covid causes ARDS. The cornerstone of ARDS management is lung protective ventilation → reduce mechanical stress on the…
@PulmCrit @JAMA_current @gattinon "[...]Groeneveld acknowledges. There needs to be a direct comparison between the two ventilation protocols." https://t.co/6BNIbJeABQ
https://t.co/QmnAnEUVB0
@ScottAdamsSays @WriteWingLeft1 It took more years before this became the norm. And this newer norm may still be too much volume for covid-lung. https://t.co/KD0XYRDrBB
RT @david_furfaro: 2/Covid causes ARDS. The cornerstone of ARDS management is lung protective ventilation → reduce mechanical stress on the…
RT @david_furfaro: 2/Covid causes ARDS. The cornerstone of ARDS management is lung protective ventilation → reduce mechanical stress on the…
2/Covid causes ARDS. The cornerstone of ARDS management is lung protective ventilation → reduce mechanical stress on the lung → minimize ventilator-induced lung injury. The landmark ARMA trial showed lower tidal volume ventilation helps in this effort https://t.co/MBybOQJC6K
From original ARDSNet paper. "For patients with severe dyspnea, the tidal volume could be increased to 7 to 8 ml per kilogram of predicted body weight if the plateau pressure remained 30 cm of water or less." https://t.co/CEJKmcf1lu
@Jacob_Bogers @RyanMarino @mathewi @SortaBad I’m not sure I understand your question. There’s no medical term called “overpressure.” Maybe this will help (avoiding prolonged excessive mean airway pressure and tidal volume has been standard of care for decades): https://t.co/rqN2Oj59ms
TIDAL VOLUME Volume (mL) in every breath that is either machine or patient triggered Volume should be based on ideal body weight, starting at approximately 6mL/Kg of ideal body weight per ARDSnet. https://t.co/QbNNYRyWCl
RT @jsenior64: @heiderespinel https://t.co/za9KAHgcfJ
@heiderespinel https://t.co/za9KAHgcfJ
RT @InternAtWork: ICU/ID WEEK DAY 6 - ARDS Podcast: https://t.co/frsdHkTVSm EBM Article: https://t.co/xzsLaKZbAp https://t.co/pvlbJMAlNW
RT @InternAtWork: ICU/ID WEEK DAY 6 - ARDS Podcast: https://t.co/frsdHkTVSm EBM Article: https://t.co/xzsLaKZbAp https://t.co/pvlbJMAlNW
RT @InternAtWork: ICU/ID WEEK DAY 6 - ARDS Podcast: https://t.co/frsdHkTVSm EBM Article: https://t.co/xzsLaKZbAp https://t.co/pvlbJMAlNW
ICU/ID WEEK DAY 6 - ARDS Podcast: https://t.co/frsdHkTVSm EBM Article: https://t.co/xzsLaKZbAp https://t.co/pvlbJMAlNW
We’ve know for at least 20 years that the way we ventilate can significantly influence outcomes. https://t.co/nmZpIfHwOn
@ZDoggMD I thought standard of care was already low volume Tidal Volume. Per your video the other day & https://t.co/UQHsO6zpO7
@PeterAnderton10 @LittleNinjaUK ... Sedation of patients on low tidal volume ventilation was needed because the patient would fight the ventilator due to uncomfortable blood CO2 levels. The study that kicked off this strategy is linked below. 2/ https://t.co/MhS6wJpptX
Up first for the #CCMJC (#criticalcaremedicinejournalclub), the very fitting topic of the low TVs in ARDS. #SoMe4Surgery #medtwitter #critcaremed #CriticalCare https://t.co/CHJ7zauest
RT @TomPoole007: LOW TIDAL VOLUME STRATEGY 40% lower of mortality on ventilator. Prone position is important. https://t.co/P4IGSm0vmC T…
RT @TomPoole007: LOW TIDAL VOLUME STRATEGY 40% lower of mortality on ventilator. Prone position is important. https://t.co/P4IGSm0vmC T…
@lizziepresser @lizziepresser can you ask your source if they know of using low-TV for ventilators? High-TV tends to worsen alveolar inflammation. From NEJM: Low TV Ventilation: https://t.co/hOKDDeCShJ Neuromuscular Blockers: https://t.co/F61sDzNWhe Prone Positioning: https://t.co/Hda8GXRwet
COVID-19 Research Links: Open Research Dataset: https://t.co/wt3oAft7KX NEJM: https://t.co/hu2lWuAGQ3 Neuromuscular Blockers in ARDS (NEJM): https://t.co/TAzOI2k7I7 Prone Positioning in ARDS (NEJM): https://t.co/9zwaRyI4t6 Low TV Ventilation (NEJM): https://t.co/QhV5OABL1H
LOW TIDAL VOLUME STRATEGY 40% lower of mortality on ventilator. Prone position is important. https://t.co/P4IGSm0vmC Tidal Volume https://t.co/6Qf4e6B4Fg Prone https://t.co/Upp9t5qIOw @MichelePaduano #Ventilators #intensivecare #lungs #pneumonia #pandemicposts
RT @EmiroBuendia: #Residentnudge
RT @EmiroBuendia: #Residentnudge
RT @EmiroBuendia: #Residentnudge
RT @EmiroBuendia: #Residentnudge
RT @EmiroBuendia: #Residentnudge
RT @EmiroBuendia: #Residentnudge
#Residentnudge
@aribindi “ which involved an initial tidal volume of 6 ml per kilogram of predicted body weight and a plateau pressure of 30 cm of water or less.” Probably ends up being very similar I bet and keeping Ppl 30 cm or less probably more important https://t.co/ylYZO5dNQ3
@davidmanheim @ryancareyai @AvalancheJohn @robinhanson @WeekendSjw Minimized oxygen flows reduces inflammation in the lungs. You don’t want to stretch the lungs. https://t.co/BfUr0rhEid
Referencias:
-Si tiene sospecha o certeza de SDRA no realice maniobras de reclutamiento Escalona da con PEEP, aplique estudio ARMA, ya que reclutar aumenta mortalidad ART Trial
#Residentnudge
In case anyone needs the link to the ARDSnet article https://t.co/UY93aUo1mB
RT @NEJM: From the #NEJMArchive: Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and…
RT @NEJM: From the #NEJMArchive: Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and…
RT @NEJM: From the #NEJMArchive: Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and…
RT @NEJM: From the #NEJMArchive: Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and…
RT @NEJM: From the #NEJMArchive: Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and…
RT @NEJM: From the #NEJMArchive: Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and…
RT @NEJM: From the #NEJMArchive: Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and…
RT @NEJM: From the #NEJMArchive: Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and…
RT @NEJM: From the #NEJMArchive: Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and…
RT @NEJM: From the #NEJMArchive: Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and…
RT @NEJM: From the #NEJMArchive: Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and…
RT @NEJM: From the #NEJMArchive: Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and…
From the #NEJMArchive: Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome (May 4, 2000) https://t.co/WppIJ8uUJH https://t.co/ccXFKBjvZl
7. Perhaps the most transformative trial in Critical Care Medicine is the ARDSNet trial (NEJM 2000). Lung Protective Ventilation (LPV; 6cc/Kg) showed mortality benefit over ⬆️ pressures (10-12cc/Kg). ARDSNet Trial (@NEJM 2000): https://t.co/36HWXzNanj
Journal Club Wed 8am: The Acute Respiratory Distress Syndrome Network. Ventilation with Lower Tidal Volumes as C... https://t.co/E2ig2weWDE
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