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BMC Anesthesiology Aug 2016Not only arterial hypoxemia but acute lung injury also has become the major concerns of one-lung ventilation (OLV). The use of pressure-controlled ventilation (PCV) for... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Not only arterial hypoxemia but acute lung injury also has become the major concerns of one-lung ventilation (OLV). The use of pressure-controlled ventilation (PCV) for OLV offers the potential advantages of lower airway pressure and intrapulmonary shunt, which result in a reduced risk of barotrauma and improved oxygenation, respectively.
METHODS
We searched Medline, Embase, the Cochrane central register of controlled trials and KoreaMedto find publications comparing the effects of PCV with those of volume-controlled ventilation (VCV) during intraoperative OLV in adults. A meta-analysis of randomized controlled trials was performed using the Cochrane Review Methods.
RESULTS
Six studies (259 participants) were included. The PaO2/FiO2 ratio in PCV was higher than in VCV [weighted mean difference (WMD) = 11.04 mmHg, 95 % confidence interval (CI) = 0.30 to 21.77, P = 0.04, I(2) = 3 %] and peak inspiratory pressure was significantly lower in PCV (WMD = -4.91 cm H2O, 95 % CI = -7.30 to -2.53, P < 0.0001, I (2) = 91 %). No differences in PaCO2, tidal volume, heart rate and blood pressure were observed. There were also no differences incompliance, plateau and mean airway pressure.
CONCLUSIONS
Our meta-analysis provided the evidence of improved oxygenation in PCV. However, it is difficult to draw any definitive conclusions due to the fact that the duration of ventilation in the studies reviewed was insufficient to reveal clinically relevant benefits or disadvantages of PCV. Significantly lower peak inspiratory pressure is the advantage of PCV.
Topics: Humans; One-Lung Ventilation; Positive-Pressure Respiration; Respiration, Artificial
PubMed: 27581657
DOI: 10.1186/s12871-016-0238-6 -
The Cochrane Database of Systematic... Oct 2016The rising prevalence of autism spectrum disorder (ASD) has increased the need for evidence-based treatments to lessen the impact of symptoms. Presently, no therapies... (Review)
Review
BACKGROUND
The rising prevalence of autism spectrum disorder (ASD) has increased the need for evidence-based treatments to lessen the impact of symptoms. Presently, no therapies are available to effectively treat individuals with all of the symptoms of this disorder. It has been suggested that hyperbaric oxygen therapy may alleviate the biochemical dysfunction and clinical symptoms of ASD.
OBJECTIVES
To determine whether treatment with hyperbaric oxygen:1. improves core symptoms of ASD, including social communication problems and stereotypical and repetitive behaviors;2. improves noncore symptoms of ASD, such as challenging behaviors;3. improves comorbid states, such as depression and anxiety; and4. causes adverse effects.
SEARCH METHODS
On 10 December 2015, we searched CENTRAL, Ovid MEDLINE, Embase, and 15 other databases, four of which were Chinese language databases. We also searched multiple trial and research registers.
SELECTION CRITERIA
We selected randomized controlled trials (RCTs) and quasi-RCTs of any dose, duration, and frequency for hyperbaric oxygen therapy compared with no treatment or sham treatment for children and adults with ASD.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by The Cochrane Collaboration, in that three review authors independently selected studies, assessed them for risk of bias, and extracted relevant data. We also assessed the quality of the evidence by using the GRADE approach.
MAIN RESULTS
We included one trial with a total of 60 children with a diagnosis of ASD who randomly received hyperbaric oxygen therapy or a sham treatment. Using GRADE criteria, we rated the quality of the evidence as low because of the small sample size and wide confidence intervals (CIs). Other problems included selection bias and short duration or follow-up.Overall, study authors reported no improvement in social interaction and communication, behavioral problems, communication and linguistic abilities, or cognitive function. With regard to the safety of hyperbaric oxygen therapy (adverse events), they reported minor-grade ear barotrauma events. Investigators found significant differences between groups in total number of side effect events (Peto odds ratio (OR) 3.87, 95% CI 1.53 to 9.82) and in the number of children who experienced side effects (Peto OR 4.40, 95% CI 1.33 to 14.48).
AUTHORS' CONCLUSIONS
To date, there is no evidence that hyperbaric oxygen therapy improves core symptoms and associated symptoms of ASD. It is important to note that adverse effects (minor-grade ear barotrauma events) can occur. Given the absence of evidence of effectiveness and the limited biological plausibility and possible adverse effects, the need for future RCTs of hyperbaric oxygen therapy must be carefully considered.
Topics: Autism Spectrum Disorder; Child; Child, Preschool; Cognition; Communication; Humans; Hyperbaric Oxygenation; Interpersonal Relations; Randomized Controlled Trials as Topic
PubMed: 27737490
DOI: 10.1002/14651858.CD010922.pub2 -
Respiratory Care May 2011Studies of ventilation strategies that included higher PEEP in patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) have yielded... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Studies of ventilation strategies that included higher PEEP in patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) have yielded conflicting results.
OBJECTIVE
To determine whether higher PEEP during volume-limited and pressure-limited ventilation is associated with 28-day mortality or barotrauma rates in patients with ALI/ARDS.
METHODS
We searched MEDLINE, CENTRAL, EMBASE, CINAHL, Web of Science, and the bibliographies of retrieved papers to identify randomized controlled trials that compared higher and lower PEEP in adult patients with ALI/ARDS who were already receiving volume-limited or pressure-limited ventilation. Two of us independently abstracted study-level data, including study design, patient characteristics, study methods, intervention, and main results. We pooled the study-level data with a random-effects model, unless heterogeneity was low (I(2) < 50%), in which case we used a fixed-effects model. The primary outcome was 28-day mortality.
RESULTS
Four randomized trials (2,360 participants) were evaluated. Higher PEEP had a nonsignificant trend toward lower 28-day mortality (pooled relative risk 0.90, 95% CI 0.79-1.02). There was no difference in barotrauma between the 2 groups (pooled relative risk 1.17, 95% CI 0.90-1.52). Two studies reported an adjusted hospital death rate, and the pooled results of sensitivity analysis with those adjusted rates were identical to those of the unadjusted analysis.
CONCLUSIONS
In 4 recent studies that used volume-limited or pressure-limited ventilation in ALI/ARDS patients, higher PEEP was not associated with significantly different short-term mortality or barotrauma. This study does not support the routine use of higher PEEP in patients with ALI/ARDS.
Topics: Acute Lung Injury; Humans; Positive-Pressure Respiration; Practice Guidelines as Topic; Survival Rate; United States
PubMed: 21276322
DOI: 10.4187/respcare.01011 -
Annals of the American Thoracic Society Oct 2017Trials investigating use of lower tidal volumes and inspiratory pressures for patients with acute respiratory distress syndrome (ARDS) have shown mixed results. (Meta-Analysis)
Meta-Analysis Review
RATIONALE
Trials investigating use of lower tidal volumes and inspiratory pressures for patients with acute respiratory distress syndrome (ARDS) have shown mixed results.
OBJECTIVES
To compare clinical outcomes of mechanical ventilation strategies that limit tidal volumes and inspiratory pressures (LTV) to strategies with tidal volumes of 10 to 15 ml/kg among patients with ARDS.
METHODS
This is a systematic review and meta-analysis of clinical trials investigating LTV mechanical ventilation strategies. We used random effects models to evaluate the effect of LTV on 28-day mortality, organ failure, ventilator-free days, barotrauma, oxygenation, and ventilation. Our primary analysis excluded trials for which the LTV strategy was combined with the additional strategy of higher positive end-expiratory pressure (PEEP), but these trials were included in a stratified sensitivity analysis. We performed metaregression of tidal volume gradient achieved between intervention and control groups on mortality effect estimates. We used Grading of Recommendations Assessment, Development, and Evaluation methodology to determine the quality of evidence.
RESULTS
Seven randomized trials involving 1,481 patients met eligibility criteria for this review. Mortality was not significantly lower for patients receiving an LTV strategy (33.6%) as compared with control strategies (40.4%) (relative risk [RR], 0.87; 95% confidence interval [CI], 0.70-1.08; heterogeneity statistic I = 46%), nor did an LTV strategy significantly decrease barotrauma or ventilator-free days when compared with a lower PEEP strategy. Quality of evidence for clinical outcomes was downgraded for imprecision. Metaregression showed a significant inverse association between larger tidal volume gradient between LTV and control groups and log odds ratios for mortality (β, -0.1587; P = 0.0022). Sensitivity analysis including trials that protocolized an LTV/high PEEP cointervention showed lower mortality associated with LTV (nine trials and 1,629 patients; RR, 0.80; 95% CI, 0.66-0.98; I = 46%). Compared with trials not using a high PEEP cointervention, trials using a strategy of LTV combined with high PEEP showed a greater mortality benefit (RR, 0.58; 95% CI, 0.41-0.82; P for interaction = 0.05).
CONCLUSIONS
The trend toward lower mortality with LTV ventilation in the primary analysis and the significant relationship between the degree of tidal volume reduction and the mortality effect together suggest, but do not prove, that LTV ventilation improves mortality among critically ill adults with ARDS.
Topics: Adult; Humans; Positive-Pressure Respiration; Randomized Controlled Trials as Topic; Respiratory Distress Syndrome; Tidal Volume; Ventilator-Induced Lung Injury
PubMed: 28846440
DOI: 10.1513/AnnalsATS.201704-337OT -
Pediatric Pulmonology Jul 2021High-frequency oscillatory ventilation (HFOV) is an alternative mechanical ventilation mode proposed to reduce ventilator-induced lung injuries and improve clinical... (Meta-Analysis)
Meta-Analysis
BACKGROUND
High-frequency oscillatory ventilation (HFOV) is an alternative mechanical ventilation mode proposed to reduce ventilator-induced lung injuries and improve clinical outcomes. The aim of this study was to determine the effects of HFOV compared to conventional mechanical ventilation (CMV) when used in children with hypoxemic respiratory failure.
METHODS
The literature search was conducted to identify all studies published before December 2020. Eligible studies included a population aged between 28 days and 18 years old, presented original data from randomized controlled trials (RCTs) or observational studies, compared the use of HFOV with CMV. Meta-analyses of the pooled data were performed by using random-effects models with inverse-variance weighting.
RESULTS
A total of 11 studies (2605 cases) were included, most of them evaluating patients with acute respiratory distress syndrome. The mean age of participants was 8.2 months and the mean oxygenation index of those included in the RCTs was 24.4. The effect of HFOV on mortality was not significant, and clinically significant harm or benefit could not be excluded (risk ratio [RR], 0.93; 95% confidence interval [CI], 0.72 to 1.20). No significant difference between groups was found in duration of mechanical ventilation (-2.23; 95% CI, -5.07 to 0.61), treatment failure (RR, 0.28; 95% CI, 0.08 to 1.02), and occurrence of barotrauma (RR, 0.88; 95% CI, 0.39 to 1.99).
CONCLUSION
The scarce evidence currently available does not allow us to conclude that HFOV has advantages over CMV and further studies are needed to clarify its role in the treatment of acute hypoxemic respiratory failure in children.
Topics: Adult; Child; Child, Preschool; High-Frequency Ventilation; Humans; Intermittent Positive-Pressure Ventilation; Respiration, Artificial; Respiratory Distress Syndrome; Respiratory Insufficiency
PubMed: 33902159
DOI: 10.1002/ppul.25428 -
Critical Care (London, England) Mar 2013Randomized trials investigating neuromuscular blocking agents in adult acute respiratory distress syndrome (ARDS) have been inconclusive about effects on mortality,... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Randomized trials investigating neuromuscular blocking agents in adult acute respiratory distress syndrome (ARDS) have been inconclusive about effects on mortality, which is very high in this population. Uncertainty also exists about the associated risk of ICU-acquired weakness.
METHODS
We conducted a systematic review and meta-analysis. We searched the Cochrane (Central) database, MEDLINE, EMBASE, ACP Journal Club, and clinical trial registries for randomized trials investigating survival effects of neuromuscular blocking agents in adults with ARDS. Two independent reviewers abstracted data and assessed methodologic quality. Primary study investigators provided additional unpublished data.
RESULTS
Three trials (431 patients; 20 centers; all from the same research group in France) met inclusion criteria for this review. All trials assessed 48-hour infusions of cisatracurium besylate. Short-term infusion of cisatracurium besylate was associated with lower hospital mortality (RR, 0.72; 95% CI, 0.58 to 0.91; P=0.005; I2=0). This finding was robust on sensitivity analyses. Neuromuscular blockade was also associated with lower risk of barotrauma (RR, 0.43; 95% CI, 0.20 to 0.90; P=0.02; I2=0), but had no effect on the duration of mechanical ventilation among survivors (MD, 0.25 days; 95% CI, 5.48 to 5.99; P=0.93; I2=49%), or the risk of ICU-acquired weakness (RR, 1.08; 95% CI, 0.83 to 1.41; P=0.57; I2=0). Primary studies lacked protracted measurements of weakness.
CONCLUSIONS
Short-term infusion of cisatracurium besylate reduces hospital mortality and barotrauma and does not appear to increase ICU-acquired weakness for critically ill adults with ARDS.
Topics: Atracurium; Humans; Neuromuscular Blocking Agents; Randomized Controlled Trials as Topic; Respiration, Artificial; Respiratory Distress Syndrome
PubMed: 23497608
DOI: 10.1186/cc12557 -
BMJ Clinical Evidence Sep 2007Changes in air pressure during flying can cause ear-drum pain and perforation, vertigo, and hearing loss. It has been estimated that 10% of adults and 22% of children... (Review)
Review
INTRODUCTION
Changes in air pressure during flying can cause ear-drum pain and perforation, vertigo, and hearing loss. It has been estimated that 10% of adults and 22% of children might have damage to the ear drum after a flight, although perforation is rare. Symptoms usually resolve spontaneously.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of interventions to prevent middle ear pain during air travel? We searched: Medline, Embase, The Cochrane Library and other important databases up to April 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 4 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: nasal balloon inflation, oral pseudoephedrine, and topical nasal decongestants.
Topics: Administration, Oral; Air Travel; Barotrauma; Ear, Middle; Earache; Humans; Incidence; Nasal Decongestants; Pain; Travel
PubMed: 19450303
DOI: No ID Found -
Journal of Critical Care Oct 2021To determine whether higher positive end- expiratory pressure (PEEP) could provide a survival advantage for patients without acute respiratory distress syndrome (ARDS)... (Meta-Analysis)
Meta-Analysis Review
Effect of different levels of PEEP on mortality in ICU patients without acute respiratory distress syndrome: systematic review and meta-analysis with trial sequential analysis.
OBJECTIVE
To determine whether higher positive end- expiratory pressure (PEEP) could provide a survival advantage for patients without acute respiratory distress syndrome (ARDS) compared with lower PEEP.
METHODS
Eligible studies were identified through searches of Embase, Cochrane Library, Web of Science, Medline, and Wanfang database from inception up to 1 June 2021. Trial sequential analysis (TSA) was used in this meta-analysis.
DATA SYNTHESIS
Twenty-seven randomized controlled trials (RCTs) were identified for further evaluation. Higher and lower PEEP arms included 1330 patients and 1650 patients, respectively. A mean level of 9.6±3.4 cmHO was applied in the higher PEEP groups and 1.9±2.6 cmHO was used in the lower PEEP groups. Higher PEEP, compared with lower PEEP, was not associated with reduction of all-cause mortality (RR 1.03; 95% CI 0.91-1.18; P =0.627), and 28-day mortality (RR 1.07 ; 95% CI 0.92-1.24; P =0.365). In terms of risk of ARDS (RR 0.43; 95% CI 0.24-0.78; P =0.005), duration of intensive care unit (MD -1.04; 95%CI-1.36 to -0.73; P < 0.00001), and oxygenation (MD 40.30; 95%CI 0.94 to 79.65; P = 0.045), higher PEEP was superior to lower PEEP. Besides, the pooled analysis showed no significant differences between groups both in the duration of mechanical ventilation (MD 0.00; 95%CI-0.13 to 0.13; P = 0.996) and hospital stay (MD -0.66; 95%CI-1.94 to 0.61; P = 0.309). More importantly, lower PEEP did not increase the risk of pneumonia, atelectasis, barotrauma, hypoxemia, or hypotension among patients compared with higher PEEP. The TSA analysis showed that the results of all-cause mortality and 28-day mortality might be false-negative results.
CONCLUSIONS
Our results suggest that a lower PEEP ventilation strategy was non-inferior to a higher PEEP ventilation strategy in ICU patients without ARDS, with no increased risk of all-cause mortality and 28-day mortality. Further high-quality RCTs should be performed to confirm these findings.
Topics: Humans; Intensive Care Units; Length of Stay; Positive-Pressure Respiration; Respiration, Artificial; Respiratory Distress Syndrome
PubMed: 34274832
DOI: 10.1016/j.jcrc.2021.06.015 -
Annals of the American Thoracic Society Oct 2017Higher positive end-expiratory pressure (PEEP) levels may reduce atelectrauma, but increase over-distention lung injury. Whether higher PEEP improves clinical outcomes... (Meta-Analysis)
Meta-Analysis Review
RATIONALE
Higher positive end-expiratory pressure (PEEP) levels may reduce atelectrauma, but increase over-distention lung injury. Whether higher PEEP improves clinical outcomes among patients with acute respiratory distress syndrome (ARDS) is unclear.
OBJECTIVES
To compare clinical outcomes of mechanical ventilation strategies using higher PEEP levels versus lower PEEP strategies in patients with ARDS.
METHODS
We performed a systematic review and meta-analysis of clinical trials investigating mechanical ventilation strategies using higher versus lower PEEP levels. We used random effects models to evaluate the effect of higher PEEP on 28-day mortality, organ failure, ventilator-free days, barotrauma, oxygenation, and ventilation.
RESULTS
We identified eight randomized trials comparing higher versus lower PEEP strategies, enrolling 2,728 patients with ARDS. Patients were 55 (±16) (mean ± SD) years old and 61% were men. Mean PEEP in the higher PEEP groups was 15.1 (±3.6) cm HO as compared with 9.1 (±2.7) cm HO in the lower PEEP groups. Primary analysis excluding two trials that did not use lower Vt ventilation in the lower PEEP control groups did not demonstrate significantly reduced mortality for patients receiving higher PEEP as compared with a lower PEEP (six trials; 2,580 patients; relative risk, 0.91; 95% confidence interval [CI] = 0.80-1.03). A higher PEEP strategy also did not significantly decrease barotrauma, new organ failure, or ventilator-free days when compared with a lower PEEP strategy (moderate-level evidence). Quality of evidence for primary analyses was downgraded for precision, as CIs of outcomes included estimates that would result in divergent recommendations for use of higher PEEP. Secondary analysis, including trials that did not use low Vt in low-PEEP control groups, showed significant mortality reduction for high-PEEP strategies (eight trials; 2,728 patients; relative risk, 0.84; 95% CI = 0.71-0.99), with greater mortality benefit observed for high PEEP in trials that did not use lower Vts in the low-PEEP control group (P = 0.02). Analyses stratifying by use of recruitment maneuvers (P for interaction = 0.69), or use of physiological targets to set PEEP versus PEEP/Fi tables (P for interaction = 0.13), did not show significant effect modification.
CONCLUSIONS
Use of higher PEEP is unlikely to improve clinical outcomes among unselected patients with ARDS.
Topics: Adult; Hospital Mortality; Humans; Positive-Pressure Respiration; Randomized Controlled Trials as Topic; Respiratory Distress Syndrome; Tidal Volume; Ventilator-Induced Lung Injury
PubMed: 29043834
DOI: 10.1513/AnnalsATS.201704-338OT -
Advances in Neonatal Care : Official... Oct 2021Although it is well established that standardized treatment protocols improve outcomes for infants with congenital diaphragmatic hernia (CDH), there remains variance...
BACKGROUND
Although it is well established that standardized treatment protocols improve outcomes for infants with congenital diaphragmatic hernia (CDH), there remains variance between existing protocols.
PURPOSE
The purpose of this article was to review current literature on protocols for CDH management in the preoperative period and to describe a care pathway integrating best practice elements from existing literature with volume-targeted ventilation strategies previously in place at a major tertiary care center in the Pacific Northwestern United States.
METHODS/SEARCH STRATEGY
A systematic review of literature was performed according to PRISMA guidelines to identify current publications on CDH protocols and examine them for similarities and differences, particularly regarding ventilation strategies.
FINDINGS/RESULTS
Although existing protocols from multiple regions worldwide shared common goals of reducing barotrauma and delaying surgery until a period of clinical stabilization was achieved, their strategies varied. None included volume-targeted ventilation with pressure limitation as a method of avoiding ventilation-induced lung injury (VILI).
IMPLICATIONS FOR PRACTICE
Institutions that routinely manage infants with CDH should have a standardized treatment protocol in place, as this is shown to improve outcomes. This may include volume-targeted ventilation with pressure limitation as a successful VILI-limiting strategy.
IMPLICATIONS FOR RESEARCH
While standardized protocols have been shown to increase survival rate for infants with CDH, more research is needed to determine what these protocols should include. Specifically, there is a need for future study on the most appropriate ventilation mode for this population.
Topics: Clinical Protocols; Hernias, Diaphragmatic, Congenital; Humans; Infant; Lung Injury; Respiration, Artificial; Survival Rate
PubMed: 33843783
DOI: 10.1097/ANC.0000000000000863