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Burns : Journal of the International... Jun 2020Ventilation strategies aiming at prevention of ventilator-induced lung injury (VILI), including low tidal volumes (V) and use of positive end-expiratory pressures (PEEP)...
OBJECTIVE
Ventilation strategies aiming at prevention of ventilator-induced lung injury (VILI), including low tidal volumes (V) and use of positive end-expiratory pressures (PEEP) are increasingly used in critically ill patients. It is uncertain whether ventilation practices changed in a similar way in burn patients. Our objective was to describe applied ventilator settings and their relation to development of VILI in burn patients.
DATA SOURCES
Systematic search of the literature in PubMed and EMBASE using MeSH, EMTREE terms and keywords referring to burn or inhalation injury and mechanical ventilation.
STUDY SELECTION
Studies reporting ventilator settings in adult or pediatric burn or inhalation injury patients receiving mechanical ventilation during the ICU stay.
DATA EXTRACTION
Two authors independently screened abstracts of identified studies for eligibility and performed data extraction.
DATA SYNTHESIS
The search identified 35 eligible studies. V declined from 14 ml/kg in studies performed before to around 8 ml/kg predicted body weight in studies performed after 2006. Low-PEEP levels (<10 cmHO) were reported in 70% of studies, with no changes over time. Peak inspiratory pressure (PIP) values above 35 cmHO were frequently reported. Nevertheless, 75% of the studies conducted in the last decade used limited maximum airway pressures (≤35 cmHO) compared to 45% of studies conducted prior to 2006. Occurrence of barotrauma, reported in 45% of the studies, ranged from 0 to 29%, and was more frequent in patients ventilated with higher compared to lower airway pressures.
CONCLUSION
This systematic review shows noticeable trends of ventilatory management in burn patients that mirrors those in critically ill non-burn patients. Variability in available ventilator data precluded us from drawing firm conclusions on the association between ventilator settings and the occurrence of VILI in burn patients.
Topics: Barotrauma; Burns; Humans; Positive-Pressure Respiration; Respiration, Artificial; Smoke Inhalation Injury; Tidal Volume; Ventilator-Induced Lung Injury
PubMed: 31202528
DOI: 10.1016/j.burns.2019.05.015 -
Intensive Care Medicine Sep 2014To assess the effects of alveolar recruitment maneuvers (ARMs) on clinical outcomes in patients with acute respiratory distress syndrome (ARDS). (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To assess the effects of alveolar recruitment maneuvers (ARMs) on clinical outcomes in patients with acute respiratory distress syndrome (ARDS).
METHODS
We conducted a search of the MEDLINE, EMBASE, LILACS, CINAHL, CENTRAL, Scopus, and Web of Science (from inception to July 2014) databases for all (i.e. no language restriction) randomized controlled trials (RCTs) evaluating the effects of ARMs versus no ARMs in adults with ARDS. Four teams of two reviewers independently assessed the eligibility of the studies identified during the search and appraised the risk of bias and extracted data from those which were assessed as meeting the inclusion criteria. Data were pooled using the random-effects model. Trial sequential analysis (TSA) was used to establish monitoring boundaries to limit global type I error due to repetitive testing for our primary outcome (in-hospital mortality). The GRADE system was used to rate the quality of evidence.
RESULTS
Our database search identified ten RCTs (1,594 patients, 612 events) which satisfied the inclusion criteria. The meta-analysis assessing the effect of ARMs on in-hospital mortality showed a risk ratio (RR) of 0.84 [95 % confidence interval (CI) 0.74-0.95; I(2) = 0 %], although the quality of evidence was considered to be low due to the risk of bias in the included trials and the indirectness of the evidence--that is, ARMs were usually conducted together with other ventilatory interventions which may affect the outcome of interest. There were no differences in the rates of barotrauma (RR 1.11; 95 % CI 0.78-1.57; I(2) = 0 %) or need for rescue therapies (RR 0.76, 95 % CI 0.41-1.40; I(2) = 56 %). Most trials found no difference between groups in terms of duration of mechanical ventilation and length of stay in the intensive care unit and hospital. The TSA showed that the available evidence for the effect of ARMs on in-hospital mortality is precise in the case of a type I error of 5 %, but it is not precise with a type I error of 1 %.
CONCLUSIONS
Although ARMs may decrease the mortality of patients with ARDS without increasing the risk for major adverse events, current evidence is not definitive. Large-scale ongoing trials addressing this question may provide data better applicable to clinical practice.
Topics: Hospital Mortality; Humans; Pulmonary Alveoli; Respiratory Distress Syndrome; Respiratory Therapy; Treatment Outcome
PubMed: 25097070
DOI: 10.1007/s00134-014-3413-6 -
Diabetic Medicine : a Journal of the... Jul 2019To examine the efficacy of hyperbaric oxygen therapy in healing diabetes-related lower limb ulcers through a meta-analysis of randomized clinical trials. (Meta-Analysis)
Meta-Analysis
AIM
To examine the efficacy of hyperbaric oxygen therapy in healing diabetes-related lower limb ulcers through a meta-analysis of randomized clinical trials.
METHODS
A literature search was conducted to identify appropriate clinical trials. Inclusion required randomized study design and reporting of the proportion of diabetes-related lower limb ulcers that healed. A meta-analysis was performed to examine the effect of hyperbaric oxygen therapy on ulcer healing. The secondary outcomes were minor and major amputations.
RESULTS
Nine randomized trials involving 585 participants were included. People allocated to hyperbaric oxygen therapy were more likely to have complete ulcer healing (relative risk 1.95, 95% CI 1.51-2.52; P<0.001), and less likely to require major (relative risk 0.54, 95% CI 0.36-0.81; P=0.003) or minor (relative risk 0.68, 95% CI 0.48-0.98; P=0.040) amputations than control groups. Sensitivity analyses suggested the findings were dependent on the inclusion of one trial. Adverse events included ear barotrauma and a seizure. Many of the trials were noted to have methodological weaknesses including absence of blinding of outcome assessors, lack of a justifiable sample size calculation and limited follow-up.
CONCLUSIONS
This meta-analysis suggests hyperbaric oxygen therapy improves the healing of diabetes-related lower limb ulcers and reduces the requirement for amputation. Confidence in these results is limited by significant design weaknesses of previous trials and inconsistent findings. A more rigorous assessment of the efficacy of hyperbaric the efficacy of hyperbaric oxygen therapy is needed.
Topics: Amputation, Surgical; Clinical Trials as Topic; Diabetes Mellitus; Diabetic Foot; Humans; Hyperbaric Oxygenation; Treatment Outcome; Ulcer; Wound Healing
PubMed: 31002414
DOI: 10.1111/dme.13975 -
BMJ Open Nov 2020To determine whether neuromuscular blocking agents (NMBAs) can decrease the mortality of patients with acute respiratory distress syndrome (ARDS) and improve their... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To determine whether neuromuscular blocking agents (NMBAs) can decrease the mortality of patients with acute respiratory distress syndrome (ARDS) and improve their clinical outcomes.
DESIGN
Systematic review, meta-analysis and meta-regression.
DATA SOURCES
PubMed, Embase, Cochrane Library, Web of Science and ClinicalTrials.gov.
METHODS
Randomised controlled trials (RCTs) comparing the treatment effect of NMBAs with that of placebo (or traditional treatment) in patients with ARDS were carefully selected. The primary outcome was 90-day mortality. The secondary outcomes were 21-28 days mortality, NMBA-related complications (barotrauma, pneumothorax and intensive care unit (ICU)-acquired muscle weakness), days free of ventilation and days not in the ICU by day 28, Medical Research Council score, Acute Physiology and Chronic Health Evaluation II score and arterial oxygen tension (PaO)/fractional inspired oxygen (FiO) (at 48 hours and 72 hours). Random-effects meta-regression was used to explore models involving potential moderators. Trial sequential analysis was performed to estimate the cumulative effect on mortality across RCTs.
RESULTS
NMBAs were not associated with reduced 90-day mortality (risk ratio (RR) 0.85; 95% CI 0.66 to 1.09; p=0.20). However, they decreased the 21-28 days mortality (RR 0.71; 95% CI 0.53 to 0.96; p=0.02) and the rates of pneumothorax (RR 0.46; 95% CI 0.28 to 0.77; p=0.003) and barotrauma (RR 0.56; 95% CI 0.37 to 0.86; p=0.008). In addition, NMBAs increased PaO/FiO at 48 hours (mean difference (MD) 18.91; 95% CI 4.29 to 33.53; p=0.01) and 72 hours (MD 12.27; 95% CI 4.65 to 19.89; p=0.002). Meta-regression revealed an association between sample size (p=0.042) and short-term mortality. Publication year (p=0.050), sedation strategy (p=0.047) and sample size (p=0.046) were independently associated with PaO/FiO at 48 hours.
CONCLUSIONS
In summary, the results suggested that use of NMBAs might reduce 21-28 days mortality, NMBA-related complications and oxygenation. However, NMBAs did not reduce the 90-day mortality of patients with ARDS, which contradicts a previous meta-analysis.
PROSPERO REGISTRATION NUMBER
CRD42019139440.
Topics: Adult; Humans; Intensive Care Units; Lung; Neuromuscular Blocking Agents; Prospective Studies; Respiratory Distress Syndrome
PubMed: 33444180
DOI: 10.1136/bmjopen-2020-037737 -
Korean Journal of Ophthalmology : KJO Apr 2022Central retinal artery occlusion (CRAO) is a vision-threatening condition with a potentially poor visual prognosis. Many different treatment modalities are suggested but... (Meta-Analysis)
Meta-Analysis
PURPOSE
Central retinal artery occlusion (CRAO) is a vision-threatening condition with a potentially poor visual prognosis. Many different treatment modalities are suggested but controversy remains regarding effectiveness of these treatments. The purpose of this study is to perform a systematic review and meta-analysis in addition to analyzing retrospective data at our own tertiary care center regarding effectiveness of hyperbaric oxygen therapy (HBOT) in treatment of CRAO.
METHODS
The PubMed, Scopus, and the Cochrane Library are searched from the date of database inception to September 2021 to conduct a review based on the PRISMA (preferred reporting items for systematic review and meta-analysis), evaluating the role of HBOT in visual recovery of CRAO patients. In addition, a retrospective chart review of patients clinically diagnosed with CRAO at our university-based hospital (University of Texas Health, San Antonio, TX, USA) from year 2011 to 2021 was conducted.
RESULTS
After a review of 376 articles, three articles met the inclusion criteria for meta-analysis, where a total of 207 patients received HBOT versus 89 patients that did not receive any form of oxygen therapy. Analysis of these results demonstrate that HBOT in CRAO patients does not enhance the final visual outcome (p = 0.83). Similar conclusion was also drawn from retrospective analysis of 48 patients (15 HBOT versus 33 controls) at our tertiary care center, where no visual benefit was observed in the HBOT group.
CONCLUSIONS
HBOT does not appear to improve final visual outcome and concerns remain regarding adverse reactions such as barotrauma and generalized seizures. Large, randomized studies are required for further understanding of the role of HBOT in treatment of CRAO.
Topics: Humans; Hyperbaric Oxygenation; Retinal Artery Occlusion; Retrospective Studies; Vision Disorders
PubMed: 34743490
DOI: 10.3341/kjo.2021.0130 -
Therapeutic Advances in Respiratory... 2019Setting a positive end-expiratory pressure (PEEP) on patients with acute respiratory distress syndrome (ARDS) receiving mechanical ventilation has been an issue of great... (Comparative Study)
Comparative Study Meta-Analysis
Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) low PEEP on patients with moderate-severe acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials.
BACKGROUND
Setting a positive end-expiratory pressure (PEEP) on patients with acute respiratory distress syndrome (ARDS) receiving mechanical ventilation has been an issue of great contention. Therefore, we aimed to determine effects of lung recruitment maneuver (RM) and titrated PEEP low PEEP on adult patients with moderate-severe ARDS.
METHODS
Data sources and study selection proceeded as follows: PubMed, Ovid, EBSCO, and Cochrane Library databases were searched from 2003 to May 2018. Original clinical randomized controlled trials which met the eligibility criteria were included. To compare the prognosis between the titrated PEEP and low PEEP groups on patients with moderate-severe ARDS (PaO/FiO < 200 mmHg). Heterogeneity was quantified through the statistic. Egger's test and funnel plots were used to assess publication bias.
RESULTS
No difference was found in 28-day mortality and ICU mortality (OR = 0.97, 95% CI (0.61-1.52), = 0.88; OR = 1.14, 95% CI (0.91-1.43), = 0.26, respectively). Only ventilator-free days, length of stay in the ICU, length of stay in hospital, and incidence of barotrauma could be systematically reviewed owing to bias and extensive heterogeneity.
CONCLUSION
No difference was observed in the RM between the titrated PEEP and the low PEEP in 28-day mortality and ICU mortality on patients with moderate-severe ARDS.
Topics: Adult; Hospitalization; Humans; Intensive Care Units; Positive-Pressure Respiration; Randomized Controlled Trials as Topic; Respiratory Distress Syndrome; Severity of Illness Index; Treatment Outcome
PubMed: 31269867
DOI: 10.1177/1753466619858228 -
Heart & Lung : the Journal of Critical... 2021Pneumothorax has been frequently described as a complication of COVID-19 infections.
BACKGROUND
Pneumothorax has been frequently described as a complication of COVID-19 infections.
OBJECTIVE
In this systematic review, we describe the incidence, clinical characteristics, and outcomes of COVID-19-related pneumothorax.
METHODS
Studies were identified through MEDLINE, Pubmed, and Google Scholar databases using keywords of "COVID-19," "SARS-CoV-2," "pneumothorax," "pneumomediastinum," and "barotrauma" from January 1st, 2020 to January 30th, 2021.
RESULTS
Among the nine observational studies, the incidence of pneumothorax is low at 0.3% in hospitalized COVID-19 patients. However, the incidence of pneumothorax increases to 12.8-23.8% in those requiring invasive mechanical ventilation (IMV) with a high mortality rate up to 100%. COVID-19-related pneumothorax tends to be unilateral and right-sided. Age, pre-existing lung diseases, and active smoking status are not shown to be risk factors. The time to pneumothorax diagnosis is around 9.0-19.6 days from admission and 5.4 days after IMV initiation. COVID-19-related pneumothoraces are associated with prolonged hospitalization, increased likelihood of ICU admission and death, especially among the elderly.
CONCLUSION
COVID-19-related pneumothorax likely signify greater disease severity. With the high variability of COVID-19-related pneumothorax incidence described, a well-designed study is required to better assess the significance of COVID-19-related pneumothorax.
Topics: Aged; COVID-19; Humans; Incidence; Mediastinal Emphysema; Pneumothorax; Respiration, Artificial; SARS-CoV-2
PubMed: 34087677
DOI: 10.1016/j.hrtlng.2021.04.005 -
The Cochrane Database of Systematic... Nov 2012Asthma is the most common chronic disease in children, and children with asthma frequently visit the paediatric emergency departments with acute exacerbations. Some of... (Review)
Review
BACKGROUND
Asthma is the most common chronic disease in children, and children with asthma frequently visit the paediatric emergency departments with acute exacerbations. Some of these children fail to respond to standard therapy (aerosol beta(2)-agonist with or without aerosol anticholinergic and oral or parenteral corticosteroids) for acute asthma leading to prolonged emergency department stay, hospitalisation, morbidity (e.g. barotrauma, intubation) and death, albeit rarely. Ketamine may relieve bronchospasm and is a potentially promising therapy for children with acute asthma who fail to respond to standard treatment.
OBJECTIVES
To evaluate the efficacy of ketamine compared to placebo, no intervention or standard care for management of severe acute asthma in children who had not responded to standard therapy.
SEARCH METHODS
We identified trials from the Cochrane Airways Group Specialised Register of trials (CAGR) and ClinicalTrials.gov. We reviewed reference lists of all primary studies and review articles for additional references. We contacted authors of identified trials and asked them to identify other published and unpublished studies. The latest search was in July 2012.
SELECTION CRITERIA
Randomised controlled trials comparing ketamine to placebo or standard care in children (up to 18 years of age) presenting with an acute asthma exacerbation who had not responded to standard therapy.
DATA COLLECTION AND ANALYSIS
Two review authors independently selected studies. The data were extracted in pre-defined proforma and were analysed independently by two review authors. The data analysis was performed using Review Manager 5.1.
MAIN RESULTS
A single study enrolling 68 non-intubated children was found eligible for inclusion in review. The study had low or unclear risk of bias. It demonstrated no significant difference in respiratory rate, oxygen saturation, hospital admission rate (odds ratio (OR) 0.77; 95% confidence interval (CI) 0.23 to 2.58) and need for mechanical ventilation between ketamine (0.2 mg/kg intravenous bolus over one to two minutes, followed by a 0.5 mg/kg per hour continuous infusion for two hours) and placebo group. There were no significant side effects of ketamine in the study. There was also no difference in need for other adjuvant therapy (OR 2.19; 95% CI 0.19 to 25.40) and in Pulmonary Index Score (mean difference (MD) -0.40; 95% CI -1.21 to 0.41) between the groups.
AUTHORS' CONCLUSIONS
The single study on non-intubated children with severe acute asthma did not show significant benefit and does not support the case studies and observational reports showing benefits of ketamine in both non-ventilated and ventilated children. There were no significant side effects of ketamine. We could not find any trials on ventilated children. To prove that ketamine is an effective treatment for acute asthma in children, there is need for sufficiently powered randomised trials of high methodological quality with objective outcome measures of clinical importance. Future trials should also explore different doses of ketamine and its role in children needing ventilation because of severe acute asthma.
Topics: Acute Disease; Adolescent; Asthma; Bronchodilator Agents; Child; Child, Preschool; Disease Progression; Humans; Infant; Ketamine; Randomized Controlled Trials as Topic; Respiration, Artificial
PubMed: 23152273
DOI: 10.1002/14651858.CD009293.pub2 -
JAMA Network Open Jul 2019A number of interventions are available to manage patients with moderate to severe acute respiratory distress syndrome (ARDS). However, the associations of currently... (Meta-Analysis)
Meta-Analysis
Assessment of Therapeutic Interventions and Lung Protective Ventilation in Patients With Moderate to Severe Acute Respiratory Distress Syndrome: A Systematic Review and Network Meta-analysis.
IMPORTANCE
A number of interventions are available to manage patients with moderate to severe acute respiratory distress syndrome (ARDS). However, the associations of currently available ventilatory strategies and adjunctive therapies with mortality are uncertain.
OBJECTIVES
To compare and rank different therapeutic strategies to identify the best intervention associated with a reduction in mortality in adult patients with moderate to severe ARDS.
DATA SOURCES
An electronic search of MEDLINE, MEDLINE In-Process/ePubs Ahead of Print, Embase, Cochrane Controlled Clinical Trial Register (Central), PubMed, and CINAHL was conducted, from database inception to May 29, 2019.
STUDY SELECTION
Randomized clinical trials of interventions for adults with moderate to severe ARDS that used lung protective ventilation. No language restrictions were applied.
DATA EXTRACTION AND SYNTHESIS
Data were independently extracted by 2 reviewers and synthesized with Bayesian random-effects network meta-analyses.
MAIN OUTCOMES AND MEASURES
The primary outcome was 28-day mortality. Barotrauma was a secondary outcome.
RESULTS
Among 25 randomized clinical trials evaluating 9 interventions, 2686 of 7743 patients (34.6%) died within 28 days. Compared with lung protective ventilation alone, prone positioning and venovenous extracorporeal membrane oxygenation were associated with significantly lower 28-day mortality (prone positioning: risk ratio, 0.69; 95% credible interval, 0.48-0.99; low quality of evidence; venovenous extracorporeal membrane oxygenation: risk ratio, 0.60; 95% credible interval, 0.38-0.93; moderate quality of evidence). These 2 interventions had the highest ranking probabilities, although they were not significantly different from each other. Among 18 trials reporting on barotrauma, 448 of 6258 patients (7.2%) experienced this secondary outcome. No intervention was superior to any other in reducing barotrauma, and each represented low to very low quality of evidence.
CONCLUSIONS AND RELEVANCE
This network meta-analysis supports the use of prone positioning and venovenous extracorporeal membrane oxygenation in addition to lung protective ventilation in patients with ARDS. Moreover, venovenous extracorporeal membrane oxygenation may be considered as an early strategy for adults with severe ARDS receiving lung protective ventilation.
Topics: Adult; Aged; Bayes Theorem; Extracorporeal Membrane Oxygenation; Female; Humans; Male; Middle Aged; Network Meta-Analysis; Patient Positioning; Respiration, Artificial; Respiratory Distress Syndrome
PubMed: 31365111
DOI: 10.1001/jamanetworkopen.2019.8116 -
Respiratory Medicine 2023Recent studies suggested that Macklin sign is a predictor of barotrauma in patients with acute respiratory distress syndrome (ARDS). We performed a systematic review to... (Review)
Review
INTRODUCTION
Recent studies suggested that Macklin sign is a predictor of barotrauma in patients with acute respiratory distress syndrome (ARDS). We performed a systematic review to further characterize the clinical role of Macklin.
METHODS
PubMed, Scopus, Cochrane Central Register and Embase were searched for studies reporting data on Macklin. Studies without data on chest CT, pediatric studies, non-human and cadaver studies, case reports and series including <5 patients were excluded. The primary objective was to assess the number of patients with Macklin sign and barotrauma. Secondary objectives were: occurrence of Macklin in different populations, clinical use of Macklin, prognostic impact of Macklin.
RESULTS
Seven studies enrolling 979 patients were included. Macklin was present in 4-22% of COVID-19 patients. It was associated with barotrauma in 124/138 (89.8%) of cases. Macklin sign preceded barotrauma in 65/69 cases (94.2%) 3-8 days in advance. Four studies used Macklin as pathophysiological explanation for barotrauma, two studies as a predictor of barotrauma and one as a decision-making tool. Two studies suggested that Macklin is a strong predictor of barotrauma in ARDS patients and one study used Macklin sign to candidate high-risk ARDS patients to awake extracorporeal membrane oxygenation (ECMO). A possible correlation between Macklin and worse prognosis was suggested in two studies on COVID-19 and blunt chest trauma.
CONCLUSIONS
Increasing evidence suggests that Macklin sign anticipate barotrauma in patients with ARDS and there are initial reports on use of Macklin as a decision-making tool. Further studies investigating the role of Macklin sign in ARDS are justified.
Topics: Humans; Child; Thoracic Injuries; COVID-19; Wounds, Nonpenetrating; Respiratory Distress Syndrome; Barotrauma; Respiration, Artificial
PubMed: 36863617
DOI: 10.1016/j.rmed.2023.107178