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The Cochrane Database of Systematic... Jul 2018Since the 2000s, there has been a trend towards decreasing tidal volumes for positive pressure ventilation during surgery. This an update of a review first published in... (Meta-Analysis)
Meta-Analysis Review
Intraoperative use of low volume ventilation to decrease postoperative mortality, mechanical ventilation, lengths of stay and lung injury in adults without acute lung injury.
BACKGROUND
Since the 2000s, there has been a trend towards decreasing tidal volumes for positive pressure ventilation during surgery. This an update of a review first published in 2015, trying to determine if lower tidal volumes are beneficial or harmful for patients.
OBJECTIVES
To assess the benefit of intraoperative use of low tidal volume ventilation (less than 10 mL/kg of predicted body weight) compared with high tidal volumes (10 mL/kg or greater) to decrease postoperative complications in adults without acute lung injury.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 5), MEDLINE (OvidSP) (from 1946 to 19 May 2017), Embase (OvidSP) (from 1974 to 19 May 2017) and six trial registries. We screened the reference lists of all studies retained and of recent meta-analysis related to the topic during data extraction. We also screened conference proceedings of anaesthesiology societies, published in two major anaesthesiology journals. The search was rerun 3 January 2018.
SELECTION CRITERIA
We included all parallel randomized controlled trials (RCTs) that evaluated the effect of low tidal volumes (defined as less than 10 mL/kg) on any of our selected outcomes in adults undergoing any type of surgery. We did not retain studies with participants requiring one-lung ventilation.
DATA COLLECTION AND ANALYSIS
Two authors independently assessed the quality of the retained studies with the Cochrane 'Risk of bias' tool. We analysed data with both fixed-effect (I statistic less than 25%) or random-effects (I statistic greater than 25%) models based on the degree of heterogeneity. When there was an effect, we calculated a number needed to treat for an additional beneficial outcome (NNTB) using the odds ratio. When there was no effect, we calculated the optimum information size.
MAIN RESULTS
We included seven new RCTs (536 participants) in the update.In total, we included 19 studies in the review (776 participants in the low tidal volume group and 772 in the high volume group). There are four studies awaiting classification and three are ongoing. All included studies were at some risk of bias. Participants were scheduled for abdominal surgery, heart surgery, pulmonary thromboendarterectomy, spinal surgery and knee surgery. Low tidal volumes used in the studies varied from 6 mL/kg to 8.1 mL/kg while high tidal volumes varied from 10 mL/kg to 12 mL/kg.Based on 12 studies including 1207 participants, the effects of low volume ventilation on 0- to 30-day mortality were uncertain (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.42 to 1.53; I = 0%; low-quality evidence). Based on seven studies including 778 participants, lower tidal volumes probably reduced postoperative pneumonia (RR 0.45, 95% CI 0.25 to 0.82; I = 0%; moderate-quality evidence; NNTB 24, 95% CI 16 to 160), and it probably reduced the need for non-invasive postoperative ventilatory support based on three studies including 506 participants (RR 0.31, 95% CI 0.15 to 0.64; moderate-quality evidence; NNTB 13, 95% CI 11 to 24). Based on 11 studies including 957 participants, low tidal volumes during surgery probably decreased the need for postoperative invasive ventilatory support (RR 0.33, 95% CI 0.14 to 0.77; I = 0%; NNTB 39, 95% CI 30 to 166; moderate-quality evidence). Based on five studies including 898 participants, there may be little or no difference in the intensive care unit length of stay (standardized mean difference (SMD) -0.06, 95% CI -0.22 to 0.10; I = 33%; low-quality evidence). Based on 14 studies including 1297 participants, low tidal volumes may have reduced hospital length of stay by about 0.8 days (SMD -0.15, 95% CI -0.29 to 0.00; I = 27%; low-quality evidence). Based on five studies including 708 participants, the effects of low volume ventilation on barotrauma (pneumothorax) were uncertain (RR 1.77, 95% CI 0.52 to 5.99; I = 0%; very low-quality evidence).
AUTHORS' CONCLUSIONS
We found moderate-quality evidence that low tidal volumes (defined as less than 10 mL/kg) decreases pneumonia and the need for postoperative ventilatory support (invasive and non-invasive). We found no difference in the risk of barotrauma (pneumothorax), but the number of participants included does not allow us to make definitive statement on this. The four studies in 'Studies awaiting classification' may alter the conclusions of the review once assessed.
Topics: Acute Lung Injury; Adult; Aged; Barotrauma; Body Weight; Female; Hospital Mortality; Humans; Insufflation; Intensive Care Units; Intraoperative Care; Length of Stay; Male; Middle Aged; Noninvasive Ventilation; Pneumonia; Positive-Pressure Respiration; Postoperative Care; Pulmonary Atelectasis; Randomized Controlled Trials as Topic; Tidal Volume
PubMed: 29985541
DOI: 10.1002/14651858.CD011151.pub3 -
Journal of Critical Care Apr 2019To determine if recruitment manoeuvres (RMs) would decrease 28-day mortality of patients with acute respiratory distress syndrome (ARDS) compared with standard care. (Meta-Analysis)
Meta-Analysis
PURPOSE
To determine if recruitment manoeuvres (RMs) would decrease 28-day mortality of patients with acute respiratory distress syndrome (ARDS) compared with standard care.
MATERIALS AND METHODS
Relevant randomized controlled trials (RCTs) published prior to April 26, 2018 were systematically searched. The primary outcome was mortality. The secondary outcomes were oxygenation, barotrauma or pneumothorax, the need for rescue therapies. Data were pooled using the random effects model. And the quality of evidence was assessed by the GRADE system.
RESULTS
Of 3180 identified studies, 15 were eligibly included in our analysis (N = 2755 participants). In the primary outcome, RMs were not associated with reducing 28-day mortality (RR 0.90; 95% CI 0.74-1.09), ICU mortality (RR 0.92; 95% CI 0.74-1.1), and the in-hospital mortaliy (RR 1.02; 95% CI 0.93-1.12). In the secondary outcomes, RMs could improve oxygenation (MD 37.85; 95% CI 11.08-64.61), the rates of barotrauma (RR 1.42; 95% CI 0.83-2.42) and the need for rescue therapies (RR 0.69; 95% CI 0.42-1.12) did not show any difference in the ARDS patients with RMs.
CONCLUSIONS
Earlier meta-analyses found decreased mortality with RMs, in the contrary, our results indicate that RMs could improve oxygenation without detrimental effects, but it does not appear to reduce mortality.
Topics: Adult; Critical Care; Humans; Randomized Controlled Trials as Topic; Respiration, Artificial; Respiratory Distress Syndrome; Ventilator-Induced Lung Injury
PubMed: 30453220
DOI: 10.1016/j.jcrc.2018.10.033 -
International Angiology : a Journal of... Apr 2019Endovascular treatment below-the-knee is safe and effective but limited by poor patency. Coronary drug-eluting stents (DES) may play a role in providing mechanical... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Endovascular treatment below-the-knee is safe and effective but limited by poor patency. Coronary drug-eluting stents (DES) may play a role in providing mechanical scaffolding and deliver anti-proliferative drug to the site of vascular barotrauma to reduce the incidence of restenosis. Our aim was to evaluate and compare the use of contemporary DES with standard endovascular-therapies for atherosclerotic disease of infrapopliteal arteries.
EVIDENCE ACQUISITION
We performed a meta-analysis of randomized controlled trials comparing DES with conventional treatment for symptomatic peripheral artery disease (search date 30 August 2017). The primary endpoint was primary patency. Secondary endpoints were freedom from target lesion revascularization (TLR), major amputation, sustained Rutherford class improvement and mortality.
EVIDENCE SYNTHESIS
We identified 7 trials enrolling 801 randomly assigned patients (392 DES, 409 control). At the median follow-up of 12-months DES improved rates of primary patency (OR 3.49, 95%CI 2.38-5.12, I2=0%, P<0.00001), freedom from TLR (OR 2.19, 95%CI 1.30-3.69, I2=38%, P=0.003), major amputation (OR 0.56, 95%CI 0.31-0.99, I2=0%, P=0.049), and Rutherford class improvement (OR 1.62, 95%CI 1.01-2.59, I2=65%, P=0.046), but not mortality (OR 1.05, 95%CI 0.68-1.62; I2 =0%, P=0.91) compared to control. Subgroup analysis of primary patency favoured DES coated in sirolimus analogues compared to paclitaxel (Test for subgroup differences, Chi2=6.51, df=1, P=0.01, I2=84.6%).
CONCLUSIONS
At midterm follow-up DES significantly improved rates of primary patency, re-intervention, Rutherford class improvement and major amputation for the treatment of atherosclerotic disease of infrapopliteal arteries compared to control therapy, with no effect on patient survival. Stents coated in sirolimus analogues were more effective than paclitaxel.
Topics: Amputation, Surgical; Angioplasty, Balloon; Constriction, Pathologic; Drug-Eluting Stents; Humans; Limb Salvage; Peripheral Arterial Disease; Popliteal Artery; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 30650949
DOI: 10.23736/S0392-9590.19.04049-5 -
Journal of Intensive Care 2018Clinical benefits of recruitment maneuver in ARDS patients are controversial. A number of previous studies showed possible benefits; a large recent study reported that...
Recruitment maneuver does not provide any mortality benefit over lung protective strategy ventilation in adult patients with acute respiratory distress syndrome: a meta-analysis and systematic review of the randomized controlled trials.
BACKGROUND
Clinical benefits of recruitment maneuver in ARDS patients are controversial. A number of previous studies showed possible benefits; a large recent study reported that recruitment maneuver and PEEP titration may even be harmful. This meta-analysis was designed to compare the clinical utility of recruitment maneuver with low tidal volume ventilation in adult patients with ARDS.
METHODS
Randomized controlled trials comparing recruitment maneuver and lung protective ventilation strategy with lung protective strategy ventilation protocol alone in adult patients with ARDS has been included in this meta-analysis. PubMed and Cochrane Central Register of Controlled Trials were searched from inception to 10 November 2017 to identify potentially eligible trials. Pooled risk ratio (RR) and standardized mean difference (SMD) were calculated for binary and continuous variables respectively.
RESULTS
Data of 2480 patients from 7 randomized controlled trials have been included in this meta-analysis and systemic review. Reported mortality at the longest available follow-up [RR (95% CI) 0.93 (0.80, 1.08); = 0.33], ICU mortality [RR (95% CI) 0.91 (0.76, 1.10); = 0.33] and in-hospital mortality [RR (95% CI) 0.95 (0.83, 1.08); = 0.45] were similar between recruitment maneuver group and standard lung protective ventilation group. Duration of hospital stay [SMD (95% CI) 0.00 (- 0.09, 0.10); = 0.92] and duration of ICU stays [SMD (95% CI) 0.05 (- 0.09, 0.19); = 0.49] were also similar between recruitment maneuver group and standard lung protective ventilation group. Risk of barotrauma was also similar.
CONCLUSION
Use of recruitment maneuver along with co-interventions such as PEEP titration does not provide any benefit in terms of mortality, length of ICU, and hospital stay in ARDS patients.
PubMed: 29983985
DOI: 10.1186/s40560-018-0305-9 -
The Cochrane Database of Systematic... Mar 2021In patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), mortality remains high. These patients require mechanical ventilation, which has... (Meta-Analysis)
Meta-Analysis
BACKGROUND
In patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), mortality remains high. These patients require mechanical ventilation, which has been associated with ventilator-induced lung injury. High levels of positive end-expiratory pressure (PEEP) could reduce this condition and improve patient survival. This is an updated version of the review first published in 2013.
OBJECTIVES
To assess the benefits and harms of high versus low levels of PEEP in adults with ALI and ARDS.
SEARCH METHODS
For our previous review, we searched databases from inception until 2013. For this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, and the Web of Science from inception until May 2020. We also searched for ongoing trials (www.trialscentral.org; www.clinicaltrial.gov; www.controlled-trials.com), and we screened the reference lists of included studies.
SELECTION CRITERIA
We included randomised controlled trials that compared high versus low levels of PEEP in ALI and ARDS participants who were intubated and mechanically ventilated in intensive care for at least 24 hours.
DATA COLLECTION AND ANALYSIS
Two review authors assessed risk of bias and extracted data independently. We contacted investigators to identify additional published and unpublished studies. We used standard methodological procedures expected by Cochrane.
MAIN RESULTS
We included four new studies (1343 participants) in this review update. In total, we included 10 studies (3851 participants). We found evidence of risk of bias in six studies, and the remaining studies fulfilled all criteria for low risk of bias. In eight studies (3703 participants), a comparison was made between high and low levels of PEEP, with the same tidal volume in both groups. In the remaining two studies (148 participants), the tidal volume was different between high- and low-level groups. In the main analysis, we assessed mortality occurring before hospital discharge only in studies that compared high versus low PEEP, with the same tidal volume in both groups. Evidence suggests that high PEEP may result in little to no difference in mortality compared to low PEEP (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.90 to 1.04; I² = 15%; 7 studies, 3640 participants; moderate-certainty evidence). In addition, high PEEP may result in little to no difference in barotrauma (RR 1.00, 95% CI 0.64 to 1.57; I² = 63%; 9 studies, 3791 participants; low-certainty evidence). High PEEP may improve oxygenation in patients up to the first and third days of mechanical ventilation (first day: mean difference (MD) 51.03, 95% CI 35.86 to 66.20; I² = 85%; 6 studies, 2594 participants; low-certainty evidence; third day: MD 50.32, 95% CI 34.92 to 65.72; I² = 83%; 6 studies, 2309 participants; low-certainty evidence) and probably improves oxygenation up to the seventh day (MD 28.52, 95% CI 20.82 to 36.21; I² = 0%; 5 studies, 1611 participants; moderate-certainty evidence). Evidence suggests that high PEEP results in little to no difference in the number of ventilator-free days (MD 0.45, 95% CI -2.02 to 2.92; I² = 81%; 3 studies, 1654 participants; low-certainty evidence). Available data were insufficient to pool the evidence for length of stay in the intensive care unit.
AUTHORS' CONCLUSIONS
Moderate-certainty evidence shows that high levels compared to low levels of PEEP do not reduce mortality before hospital discharge. Low-certainty evidence suggests that high levels of PEEP result in little to no difference in the risk of barotrauma. Low-certainty evidence also suggests that high levels of PEEP improve oxygenation up to the first and third days of mechanical ventilation, and moderate-certainty evidence indicates that high levels of PEEP improve oxygenation up to the seventh day of mechanical ventilation. As in our previous review, we found clinical heterogeneity - mainly within participant characteristics and methods of titrating PEEP - that does not allow us to draw definitive conclusions regarding the use of high levels of PEEP in patients with ALI and ARDS. Further studies should aim to determine the appropriate method of using high levels of PEEP and the advantages and disadvantages associated with high levels of PEEP in different ARDS and ALI patient populations.
Topics: Acute Disease; Adult; Bias; Humans; Intensive Care Units; Length of Stay; Oxygen Consumption; Positive-Pressure Respiration; Randomized Controlled Trials as Topic; Respiratory Distress Syndrome; Tidal Volume; Ventilator-Induced Lung Injury
PubMed: 33784416
DOI: 10.1002/14651858.CD009098.pub3 -
Frontiers in Pharmacology 2019The therapeutic role of neuromuscular blocking agents (NMBA) in patients with acute respiratory distress syndrome (ARDS) remains controversial.
BACKGROUND
The therapeutic role of neuromuscular blocking agents (NMBA) in patients with acute respiratory distress syndrome (ARDS) remains controversial.
METHODS
We systematically reviewed randomized controlled trials investigating the use of NMBA in ARDS patients from inception to July 2019. Relative risk (RR) was calculated for the incidence of barotrauma and mortality using the random-effect or fixed-effect model according to heterogeneity analysis.
RESULTS
Data were combined from five randomized controlled trials that included 1,461 patients (724 in the NMBA group and 737 in the control group). Pooled analysis showed that NMBA infusion did not reduce 28-day mortality (RR = 0.72, 95% confidence interval (CI) 0.44 to 1.17, =0.180, I-squared = 62.8%), but was associated with lower intensive care unit (ICU) mortality (RR = 0.60, 95% CI 0.41 to 0.88, = 0.009, I-squared = 9.2%). In addition, the incidence of barotrauma was significantly lower in patients treated with NMBA (RR = 0.53, 95% CI 0.33 to 0.84, = 0.007, I-squared = 0). However, infusion of NMBA might increase the risk of ICU-acquired weakness (RR = 1.34, 95% CI 0.97 to 1.84, = 0.066, I-squared = 0).
CONCLUSION
Infusion of NMBA could reduce ICU mortality and the incidence of barotrauma. The risk of ICU-acquired weakness was higher in moderate-to-severe ARDS patients treated with NMBA. The real effects of NMBA need to be further evaluated and confirmed by a study with a stricter design.
PubMed: 32063852
DOI: 10.3389/fphar.2019.01637