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BMC Anesthesiology Oct 2022This meta-analysis compared the quality of lung collapse and the resultant adverse reactions between the use of double-lumen endotracheal tubes (DLT) and bronchial... (Meta-Analysis)
Meta-Analysis
Comparison of the effect of double-lumen endotracheal tubes and bronchial blockers on lung collapse in video-assisted thoracoscopic surgery: a systematic review and meta-analysis.
OBJECTIVE
This meta-analysis compared the quality of lung collapse and the resultant adverse reactions between the use of double-lumen endotracheal tubes (DLT) and bronchial blockers (BB) in minimally invasive thoracic surgery.
METHODS
A search was performed in five bibliographic databases, namely PubMed, Springer, Medline, EMBASE, and Cochrane Library ignoring the original language, which identified five randomized controlled trials (RCTs) published on or before December 31, 2021. These studies were subsequently analyzed. All included studies compared the efficacy and safety of DLT and BB as a lung isolation technique in surgery. The methodological quality of each study was assessed by the Cochrane Collaboration's risk of bias tool. The quality of lung collapse and the malposition rate were adopted as the main outcome indicators. Alternatively, the intubation time and the incidence of postoperative sore throat were adopted as secondary indicators.
RESULTS
When either DLT or BB were utilized in minimally invasive thoracic surgery, no differences were observed in the quality of lung collapse (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.63 to 1.58), the intubation time (mean difference [MD], 0.06; 95% CI, -1.02 to 1.14), or the malposition rate (OR, 0.88; 95% CI, 0.37 to 2.06). However, the incidence of postoperative sore throat among patients treated with BB was significantly lower than that among patients treated with DLT (OR, 5.25; 95% CI, 2.55 to 10.75).
CONCLUSION
When utilized in minimally invasive thoracic surgery, the quality of lung collapse with DLT was identical to that with BB. However, patients treated with the latter demonstrated a significantly lower incidence of postoperative sore throat.
Topics: Humans; Thoracic Surgery, Video-Assisted; Intubation, Intratracheal; Pulmonary Atelectasis; One-Lung Ventilation; Pharyngitis
PubMed: 36309646
DOI: 10.1186/s12871-022-01876-2 -
Medicine Sep 2022This study determined whether sugammadex was associated with a lower risk of postoperative pulmonary complications and improved outcomes in lung surgeries. (Meta-Analysis)
Meta-Analysis
BACKGROUND
This study determined whether sugammadex was associated with a lower risk of postoperative pulmonary complications and improved outcomes in lung surgeries.
METHODS
A systematic literature search was conducted using PubMed, Embase, Web of Science, and the Cochrane Library from January 2000 to March 2022. The characteristics of lung surgeries using sugammadex treatment compared with control drugs and postoperative outcomes were retrieved. The primary outcome was estimated through a pooled odds ratio (OR) and its 95% confidence interval (CI) was identified using a random-effects model.
RESULTS
From 465 citations, 7 studies with 453 patients receiving sugammadex and 452 patients receiving a control were included. The risk of postoperative pulmonary complication (PPCs) was lower in the sugammadex group than in the control group. Also, it showed that the effect of sugammadex on PPCs in the subgroup analysis was significantly assessed on the basis of atelectasis or non-atelectasis. Furthermore, subgroup analysis based on the relationship between high body mass index (BMI) and PPCs also showed that sugammadex had less occurrence in both the high BMI (defined as BMI ≥ 25) and low BMI groups. No difference in length of hospital stay (LOS) between the two groups was observed.
CONCLUSION
This study observed that although reversing neuromuscular blockages with sugammadex in patients undergoing thoracic surgery recorded fewer PPCs and shorter extubation periods than conventional reversal agents, no difference in LOS, postanaesthesia care unit (PACU) stay length and chest tube insertion duration in both groups was observed.
Topics: Humans; Length of Stay; Lung; Neostigmine; Neuromuscular Blockade; Postoperative Complications; Sugammadex
PubMed: 36181093
DOI: 10.1097/MD.0000000000030876 -
British Journal of Anaesthesia Nov 2022Individualised positive end-expiratory pressure (PEEP) may optimise pulmonary compliance, thereby potentially mitigating lung injury. This meta-analysis aimed to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Individualised positive end-expiratory pressure (PEEP) may optimise pulmonary compliance, thereby potentially mitigating lung injury. This meta-analysis aimed to determine the impact of individualised PEEP vs fixed PEEP during abdominal surgery on postoperative pulmonary outcomes.
METHODS
Medical databases (PubMed, Embase, Web of Science, ScienceDirect, Google Scholar, and the China National Knowledge Infrastructure) were searched for RCTs comparing fixed vs individualised PEEP. The composite primary outcome of pulmonary complications comprised hypoxaemia, atelectasis, pneumonia, and acute respiratory distress syndrome. Secondary outcomes included oxygenation (PO/FiO) and systemic inflammatory markers (interleukin-6 [IL-6] and club cell protein-16 [CC16]). We calculated risk ratios (RRs) and mean differences (MDs) with 95% confidence interval (CI) using DerSimonian and Laird random effects models. Cochrane risk-of-bias tool was applied.
RESULTS
Ten RCTs (n=1117 patients) met the criteria for inclusion, with six reporting the primary endpoint. Individualised PEEP reduced the incidence of overall pulmonary complications (141/412 [34.2%]) compared with 183/415 (44.1%) receiving fixed PEEP (RR 0.69 [95% CI: 0.51-0.93]; P=0.016; I=43%). Risk-of-bias analysis did not alter these findings. Individualised PEEP reduced postoperative hypoxaemia (74/392 [18.9%]) compared with 110/395 (27.8%) participants receiving fixed PEEP (RR 0.68 [0.52-0.88]; P=0.003; I=0%) but not postoperative atelectasis (RR 0.93 [0.81-1.07]; P=0.297; I=0%). Individualised PEEP resulted in higher PO/FiO (MD 20.8 mm Hg [4.6-36.9]; P=0.012; I=80%) and reduced systemic inflammation (lower plasma IL-6 [MD -6.8 pg ml; -11.9 to -1.7]; P=0.009; I=6%; and CC16 levels [MD -6.2 ng ml; -8.8 to -3.5]; P<0.001; I=0%) at the end of surgery.
CONCLUSIONS
Individualised PEEP may reduce pulmonary complications, improve oxygenation, and reduce systemic inflammation after abdominal surgery.
CLINICAL TRIAL REGISTRATION
CRD42021277973.
Topics: Humans; Interleukin-6; Positive-Pressure Respiration; Pulmonary Atelectasis; Hypoxia; Inflammation
PubMed: 36031417
DOI: 10.1016/j.bja.2022.07.009 -
Frontiers in Pediatrics 2022Post-infectious bronchiolitis obliterans (PIBO) is a long-term sequela after an initial insult to the lower respiratory tract. A comprehensive understanding of the...
BACKGROUND
Post-infectious bronchiolitis obliterans (PIBO) is a long-term sequela after an initial insult to the lower respiratory tract. A comprehensive understanding of the factors that contribute to a high risk of developing PIBO is important to help define therapeutic strategies and improve prognosis.
METHODS
We performed a systematic review of published literature available in the online databases including PubMed, Embase, Web of Science, CNKI, Wan Fang, and VIP, with the last search updated on 27 January 2022. Observational studies and case-control studies that provide sufficient data to examine associations between potential risk factors and PIBO were included. Pooled odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) and heterogeneity were calculated.
RESULTS
A total of 14 risk factors were selected from 9 studies included in the analysis. The strongest risk factors were hypoxemia, mechanical ventilation, tachypnea, and wheezing. Hypoxemia conferred the greatest risk with pooled OR of 21.54 (95% CI: 10-46.36, < 0.001). Mechanical ventilation ranked second (pooled OR 14.61, 95% CI: 7.53-28.35, < 0.001). Use of γ-globulin, use of glucocorticoids, co-infection of bacteria, a history of wheezing, and being male were other prominent risk factors. The effects of premature birth, allergic rhinitis, and imaging finding (pulmonary consolidation, atelectasis, pleural effusion) are less clear and require further confirmation. Cases that developing PIBO had a lower age compared with controls (MD, -8.76 months, 95% CI: -16.50 to -1.02, = 0.03). No significant differences were observed in the duration of fever (MD, 1.74 days, 95% CI: -0.07 to 3.54, = 0.06). Children diagnosed with PIBO had higher LDH levels (MD, 264.69 U/L, 95% CI: 67.43 to 461.74, = 0.008) and duration of hospitalization (MD, 4.50 days, 95% CI: 2.63 to 6.37, < 0.001).
CONCLUSION
In this study, we found that the strongest risk factors for PIBO were hypoxemia, mechanical ventilation, tachypnea, and wheezing. Use of glucocorticoids, γ-globulin, co-infection of bacteria, a history of wheezing, and being male may also play a role. The factors discussed above can inform the generation of a clinical prediction model for the developing PIBO in children.
PubMed: 35757133
DOI: 10.3389/fped.2022.881908 -
The Cochrane Database of Systematic... Dec 2021Duchenne muscular dystrophy (DMD) is an X-linked recessive disorder characterised by progressive muscle weakness beginning in early childhood. Respiratory failure and... (Review)
Review
BACKGROUND
Duchenne muscular dystrophy (DMD) is an X-linked recessive disorder characterised by progressive muscle weakness beginning in early childhood. Respiratory failure and weak cough develop in all patients as a consequence of muscle weakness leading to a risk of atelectasis, pneumonia, or the need for ventilatory support. There is no curative treatment for DMD. Corticosteroids are the only pharmacological intervention proven to delay the onset and progression of muscle weakness and thus respiratory decline in DMD. Antioxidant treatment has been proposed to try to reduce muscle weakness in general, and respiratory decline in particular. OBJECTIVES: To assess the effects of antioxidant agents on preventing respiratory decline in people with Duchenne muscular dystrophy during the respiratory decline phase of the condition. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and two trials registers to 23 March 2021, together with reference checking, citation searching, and contact with study authors to identify additional studies.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) and quasi-RCTs that met our inclusion criteria. We included male patients with a diagnosis of DMD who had respiratory decline evidenced by a forced vital capacity (FVC%) less than 80% but greater than 30% of predicted values, receiving any antioxidant agent compared with other therapies for the management of DMD or placebo. DATA COLLECTION AND ANALYSIS: Two review authors screened studies for eligibility, assessed risk of bias of studies, and extracted data. We used standard methods expected by Cochrane. We assessed the certainty of the evidence using the GRADE approach. The primary outcomes were FVC and hospitalisation due to respiratory infections. Secondary outcomes were quality of life, adverse events, change in muscle function, forced expiratory volume in the first second (FEV1), and peak expiratory flow (PEF). MAIN RESULTS: We included one study with 66 participants who were not co-treated with corticosteroids, which was the only study to contribute data to our main analysis. We also included a study that enrolled 255 participants treated with corticosteroids, which was only available as a press release without numerical results. The studies were parallel-group RCTs that assessed the effect of idebenone on respiratory function compared to placebo. The trial that contributed numerical data included patients with a mean (standard deviation) age of 14.3 (2.7) years at the time of inclusion, with a documented diagnosis of DMD or severe dystrophinopathy with clinical features consistent with typical DMD. The overall risk of bias across most outcomes was similar and judged as 'low'. Idebenone may result in a slightly less of a decline in FVC from baseline to one year compared to placebo (mean difference (MD) 3.28%, 95% confidence interval (CI) -0.41 to 6.97; 64 participants; low-certainty evidence), and probably has little or no effect on change in quality of life (MD -3.80, 95% CI -10.09 to 2.49; 63 participants; moderate-certainty evidence) (Pediatric Quality of Life Inventory (PedsQL), range 0 to 100, 0 = worst, 100 = best quality of life). As a related but secondary outcome, idebenone may result in less of a decline from baseline in FEV1 (MD 8.28%, 95% CI 0.89 to 15.67; 53 participants) and PEF (MD 6.27%, 95% CI 0.61 to 11.93; 1 trial, 64 participants) compared to placebo. Idebenone was associated with fewer serious adverse events (RR 0.42, 95% CI 0.09 to 2.04; 66 participants; low-certainty evidence) and little to no difference in non-serious adverse events (RR 1.00, 95% CI 0.88 to 1.13; 66 participants; low-certainty evidence) compared to placebo. Idebenone may result in little to no difference in change in arm muscle function (MD -2.45 N, 95% CI -8.60 to 3.70 for elbow flexors and MD -1.06 N, 95% CI -6.77 to 4.65 for elbow extensors; both 52 participants) compared to placebo. We found no studies evaluating the outcome hospitalisation due to respiratory infection. The second trial, involving 255 participants, for which data were available only as a press release without numerical data, was prematurely discontinued due to futility after an interim efficacy analysis based on FVC. There were no safety concerns. The certainty of the evidence was low for most outcomes due to imprecision and publication bias (the lack of a full report of the larger trial, which was prematurely terminated).
AUTHORS' CONCLUSIONS
Idebenone is the only antioxidant agent tested in RCTs for preventing respiratory decline in people with DMD for which evidence was available for assessment. Idebenone may result in slightly less of a decline in FVC and less of a decline in FEV1 and PEF, but probably has little to no measurable effect on change in quality of life. Idebenone is associated with fewer serious adverse events than placebo. Idebenone may result in little to no difference in change in muscle function. Discontinuation due to the futility of the SIDEROS trial and its expanded access programmes may indicate that idebenone research in this condition is no longer needed, but we await the trial data. Further research is needed to establish the effect of different antioxidant agents on preventing respiratory decline in people with DMD during the respiratory decline phase of the condition.
Topics: Adolescent; Adrenal Cortex Hormones; Antioxidants; Child; Forced Expiratory Volume; Humans; Male; Muscular Dystrophy, Duchenne; Vital Capacity
PubMed: 34850383
DOI: 10.1002/14651858.CD013720.pub3 -
The Cochrane Database of Systematic... Nov 2021Preterm infants are at risk of lung atelectasis due to various anatomical and physiological immaturities, placing them at high risk of respiratory failure and associated... (Review)
Review
BACKGROUND
Preterm infants are at risk of lung atelectasis due to various anatomical and physiological immaturities, placing them at high risk of respiratory failure and associated harms. Nasal continuous positive airway pressure (CPAP) is a positive pressure applied to the airways via the nares. It helps prevent atelectasis and supports adequate gas exchange in spontaneously breathing infants. Nasal CPAP is used in the care of preterm infants around the world. Despite its common use, the appropriate pressure levels to apply during nasal CPAP use remain uncertain.
OBJECTIVES
To assess the effects of 'low' (≤ 5 cm HO) versus 'moderate-high' (> 5 cm HO) initial nasal CPAP pressure levels in preterm infants receiving CPAP either: 1) for initial respiratory support after birth and neonatal resuscitation or 2) following mechanical ventilation and endotracheal extubation.
SEARCH METHODS
We ran a comprehensive search on 6 November 2020 in the following databases: CENTRAL via CRS Web and MEDLINE via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs) and quasi-randomized trials.
SELECTION CRITERIA
We included RCTs, quasi-RCTs, cluster-RCTs and cross-over RCTs randomizing preterm infants of gestational age < 37 weeks or birth weight < 2500 grams within the first 28 days of life to different nasal CPAP levels.
DATA COLLECTION AND ANALYSIS
We used the standard methods of Cochrane Neonatal to collect and analyze data. We used the GRADE approach to assess the certainty of the evidence for the prespecified primary outcomes.
MAIN RESULTS
Eleven trials met inclusion criteria of the review. Four trials were parallel-group RCTs reporting our prespecified primary or secondary outcomes. Two trials randomized 316 infants to low versus moderate-high nasal CPAP for initial respiratory support, and two trials randomized 117 infants to low versus moderate-high nasal CPAP following endotracheal extubation. The remaining seven studies were cross-over trials reporting short-term physiological outcomes. The most common potential sources of bias were absent or unclear blinding of personnel and assessors and uncertain selective reporting. Nasal CPAP for initial respiratory support after birth and neonatal resuscitation None of the six primary outcomes prespecified for inclusion in the summary of findings was eligible for meta-analysis. No trials reported on moderate-severe neurodevelopmental impairment at 18 to 26 months. The remaining five outcomes were reported in a single trial. On the basis of this trial, we are uncertain whether low or moderate-high nasal CPAP levels improve the outcomes of: death or bronchopulmonary dysplasia (BPD) at 36 weeks' postmenstrual age (PMA) (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.56 to 1.85; 1 trial, 271 participants); mortality by hospital discharge (RR 1.04, 95% CI 0.51 to 2.12; 1 trial, 271 participants); BPD at 28 days of age (RR 1.10, 95% CI 0.56 to 2.17; 1 trial, 271 participants); BPD at 36 weeks' PMA (RR 0.80, 95% CI 0.25 to 2.57; 1 trial, 271 participants), and treatment failure or need for mechanical ventilation (RR 1.00, 95% CI 0.63 to 1.57; 1 trial, 271 participants). We assessed the certainty of the evidence as very low for all five outcomes due to risk of bias, a lack of consistency across multiple studies, and imprecise effect estimates. Nasal CPAP following mechanical ventilation and endotracheal extubation One of the six primary outcomes prespecified for inclusion in the summary of findings was eligible for meta-analysis. On the basis of these data, we are uncertain whether low or moderate-high nasal CPAP levels improve the outcome of treatment failure or need for mechanical ventilation (RR 1.52, 95% CI 0.92 to 2.50; 2 trials, 117 participants; I = 17%; risk difference 0.15, 95% CI -0.02 to 0.32; number needed to treat for an additional beneficial outcome 7, 95% CI -50 to 3). We assessed the certainty of the evidence as very low due to risk of bias, inconsistency across the studies, and imprecise effect estimates. No trials reported on moderate-severe neurodevelopmental impairment at 18 to 26 months or BPD at 28 days of age. The remaining three outcomes were reported in a single trial. On the basis of this trial, we are uncertain whether low or moderate-high nasal CPAP levels improve the outcomes of: death or BPD at 36 weeks' PMA (RR 0.87, 95% CI 0.51 to 1.49; 1 trial, 93 participants); mortality by hospital discharge (RR 2.94, 95% CI 0.12 to 70.30; 1 trial, 93 participants), and BPD at 36 weeks' PMA (RR 0.87, 95% CI 0.51 to 1.49; 1 trial, 93 participants). We assessed the certainty of the evidence as very low for all three outcomes due to risk of bias, a lack of consistency across multiple studies, and imprecise effect estimates. AUTHORS' CONCLUSIONS: There are insufficient data from randomized trials to guide nasal CPAP level selection in preterm infants, whether provided as initial respiratory support or following extubation from invasive mechanical ventilation. We are uncertain as to whether low or moderate-high nasal CPAP levels improve morbidity and mortality in preterm infants. Well-designed trials evaluating this important aspect of a commonly used neonatal therapy are needed.
Topics: Bronchopulmonary Dysplasia; Continuous Positive Airway Pressure; Humans; Infant; Infant, Newborn; Infant, Premature; Morbidity; Respiration, Artificial
PubMed: 34847243
DOI: 10.1002/14651858.CD012778.pub2 -
Annals of Palliative Medicine Oct 2021In clinical general thoracic surgery, the prevalence of atelectasis is relatively high. Perioperative interventions can affect the probability of patients with... (Meta-Analysis)
Meta-Analysis
BACKGROUND
In clinical general thoracic surgery, the prevalence of atelectasis is relatively high. Perioperative interventions can affect the probability of patients with atelectasis after surgery. Therefore, the incidence of perioperative intervention to prevent atelectasis after thoracic surgery was discussed using meta-analysis in this study.
METHODS
The articles were searched in the English database PubMed and Chinese databases including China National Knowledge Infrastructure (CNKI), VIP, and China Journal Full-text Database (CJFD). The duration for publication time of the articles was from the database inception to March 2021, and the articles were required to be randomized controlled trials (RCTs) using interventions [such as changing the dose of general anesthesia, continuous positive end expiratory pressure (PEEP), non-invasive pressure support ventilation, and physical therapy] after thoracic surgery (such as pulmonary lobectomy, sternum surgery, and lung cancer surgery) for the treatment of atelectasis. The software RevMan 5.3 provided by the Cochrane Collaboration was used for meta-analysis.
RESULTS
A total of 5 articles were obtained, including 375 cases in the control group and 268 cases in the intervention treatment group. A meta-analysis was performed on the included articles, combined effect model analysis results showed that compared with the control group, the use of PEEP during mechanical ventilation can significantly reduce the incidence of atelectasis [odds ratio (OR) =0.46; 95% confidence interval (CI): 0.31-0.67; Z=3.94; P<0.0001].
DISCUSSION
Perioperative intervention was more effective for postoperative atelectasis and other complications.
Topics: Humans; Positive-Pressure Respiration; Postoperative Complications; Pulmonary Atelectasis; Thoracic Surgery; Thoracic Surgical Procedures
PubMed: 34763434
DOI: 10.21037/apm-21-2441 -
Journal of Anesthesia Apr 2022Low tidal volume ventilation strategy may lead to atelectasis without proper positive end-expiratory pressure (PEEP) and recruitment maneuver (RM) settings. RM followed... (Meta-Analysis)
Meta-Analysis Review
Effects of individualized positive end-expiratory pressure combined with recruitment maneuver on intraoperative ventilation during abdominal surgery: a systematic review and network meta-analysis of randomized controlled trials.
Low tidal volume ventilation strategy may lead to atelectasis without proper positive end-expiratory pressure (PEEP) and recruitment maneuver (RM) settings. RM followed by individualized PEEP was a new method to optimize the intraoperative pulmonary function. We conducted a systematic review and network meta-analysis of randomized clinical trials to compare the effects of individualized PEEP + RM on intraoperative pulmonary function and hemodynamic with other PEEP and RM settings. The primary outcomes were intraoperative oxygenation index and dynamic compliance, while the secondary outcomes were intraoperative heart rate and mean arterial pressure. In total, we identified 15 clinical trials containing 36 randomized groups with 3634 participants. Ventilation strategies were divided into eight groups by four PEEP (L: low, M: moderate, H: high, and I: individualized) and two RM (yes or no) settings. The main results showed that IPEEP + RM group was superior to all other groups regarding to both oxygenation index and dynamic compliance. LPEEP group was inferior to LPEEP + RM, MPEEP, MPEEP + RM, and IPEEP + RM in terms of oxygenation index and LPEEP + RM, MPEEP, MPEEP + RM, HPEEP + RM, IPEEP, and IPEEP + RM in terms of dynamic compliance. All comparisons were similar for secondary outcomes. Our analysis suggested that individualized PEEP and RM may be the optimal low tidal volume ventilation strategy at present, while low PEEP without RM is not suggested.
Topics: Humans; Network Meta-Analysis; Positive-Pressure Respiration; Pulmonary Atelectasis; Randomized Controlled Trials as Topic; Tidal Volume
PubMed: 34757497
DOI: 10.1007/s00540-021-03012-9 -
The Cochrane Database of Systematic... Nov 2021Duchenne muscular dystrophy (DMD) is an X-linked recessive disorder characterised by progressive muscle weakness beginning in early childhood. Respiratory failure and... (Review)
Review
BACKGROUND
Duchenne muscular dystrophy (DMD) is an X-linked recessive disorder characterised by progressive muscle weakness beginning in early childhood. Respiratory failure and weak cough develop in all patients as a consequence of muscle weakness leading to a risk of atelectasis, pneumonia, or the need for ventilatory support. There is no curative treatment for DMD. Corticosteroids are the only pharmacological intervention proven to delay the onset and progression of muscle weakness and thus respiratory decline in DMD. Antioxidant treatment has been proposed to try to reduce muscle weakness in general, and respiratory decline in particular. OBJECTIVES: To assess the effects of antioxidant agents on preventing respiratory decline in people with Duchenne muscular dystrophy during the respiratory decline phase of the condition. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and two trials registers to 23 March 2021, together with reference checking, citation searching, and contact with study authors to identify additional studies.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) and quasi-RCTs that met our inclusion criteria. We included male patients with a diagnosis of DMD who had respiratory decline evidenced by a forced vital capacity (FVC%) less than 80% but greater than 30% of predicted values, receiving any antioxidant agent compared with other therapies for the management of DMD or placebo. DATA COLLECTION AND ANALYSIS: Two review authors screened studies for eligibility, assessed risk of bias of studies, and extracted data. We used standard methods expected by Cochrane. We assessed the certainty of the evidence using the GRADE approach. The primary outcomes were FVC and hospitalisation due to respiratory infections. Secondary outcomes were quality of life, adverse events, change in muscle function, forced expiratory volume in the first second (FEV1), and peak expiratory flow (PEF). MAIN RESULTS: We included one study with 66 participants who were not co-treated with corticosteroids, which was the only study to contribute data to our main analysis. We also included a study that enrolled 255 participants treated with corticosteroids, which was only available as a press release without numerical results. The studies were parallel-group RCTs that assessed the effect of idebenone on respiratory function compared to placebo. The trial that contributed numerical data included patients with a mean (standard deviation) age of 14.3 (2.7) years at the time of inclusion, with a documented diagnosis of DMD or severe dystrophinopathy with clinical features consistent with typical DMD. The overall risk of bias across most outcomes was similar and judged as 'low'. Idebenone may result in a slightly less of a decline in FVC from baseline to one year compared to placebo (mean difference (MD) 3.28%, 95% confidence interval (CI) -0.41 to 6.97; 64 participants; low-certainty evidence), and probably has little or no effect on change in quality of life (MD -3.80, 95% CI -10.09 to 2.49; 63 participants; moderate-certainty evidence) (Pediatric Quality of Life Inventory (PedsQL), range 0 to 100, 0 = worst, 100 = best quality of life). As a related but secondary outcome, idebenone may result in less of a decline from baseline in FEV1 (MD 8.28%, 95% CI 0.89 to 15.67; 53 participants) and PEF (MD 6.27%, 95% CI 0.61 to 11.93; 1 trial, 64 participants) compared to placebo. Idebenone was associated with fewer serious adverse events (RR 0.42, 95% CI 0.09 to 2.04; 66 participants; low-certainty evidence) and little to no difference in non-serious adverse events (RR 1.00, 95% CI 0.88 to 1.13; 66 participants; low-certainty evidence) compared to placebo. Idebenone may result in little to no difference in change in arm muscle function (MD -2.45 N, 95% CI -8.60 to 3.70 for elbow flexors and MD -1.06 N, 95% CI -6.77 to 4.65 for elbow extensors; both 52 participants) compared to placebo. We found no studies evaluating the outcome hospitalisation due to respiratory infection. The second trial, involving 255 participants, for which data were available only as a press release without numerical data, was prematurely discontinued due to futility after an interim efficacy analysis based on FVC. There were no safety concerns. The certainty of the evidence was low for most outcomes due to imprecision and publication bias (the lack of a full report of the larger trial, which was prematurely terminated).
AUTHORS' CONCLUSIONS
Idebenone is the only antioxidant agent tested in RCTs for preventing respiratory decline in people with DMD for which evidence was available for assessment. Idebenone may result in slightly less of a decline in FVC and less of a decline in FEV1 and PEF, but probably has little to no measurable effect on change in quality of life. Idebenone is associated with fewer serious adverse events than placebo. Idebenone may result in little to no difference in change in muscle function. Discontinuation due to the futility of the SIDEROS trial and its expanded access programmes may indicate that idebenone research in this condition is no longer needed, but we await the trial data. Further research is needed to establish the effect of different antioxidant agents on preventing respiratory decline in people with DMD during the respiratory decline phase of the condition.
Topics: Adolescent; Adrenal Cortex Hormones; Antioxidants; Child; Forced Expiratory Volume; Humans; Male; Muscular Dystrophy, Duchenne; Vital Capacity
PubMed: 34748221
DOI: 10.1002/14651858.CD013720.pub2 -
Journal of Critical Care Feb 2022To evaluate the effects of high and low levels of PEEP on ICU patients without ARDS. (Meta-Analysis)
Meta-Analysis
PURPOSE
To evaluate the effects of high and low levels of PEEP on ICU patients without ARDS.
METHODS
We searched public databases (including PubMed, EMBASE, Cochrane Library and Clinicaltrial.gov). The Cochrane Risk of Bias Assessment tool was used to evaluate the quality of the included studies.
RESULTS
We included 2307 patients from 24 trials. Although no significant difference was found between high and low PEEP applications in in-hospital mortality (risk ratio[RR] 0.98, 95% confidence interval[CI] [0.81, 1.19], P = 0.87), high PEEP indeed decreased the incidence of ARDS, hypoxemia, and increased the level of PaO/FIO. In addition, although the overall results did not reveal any advantages of high PEEP in terms of secondary outcomes regarding 28-day mortality, the duration of ventilation, atelectasis, pulmonary barotrauma, hypotension, and so forth, the subgroup analysis concerning the level of low PEEP (ZEEP or not) and patient type (postoperative or medical ones) yielded different results. The TSA results suggested that more RCTs are needed.
CONCLUSIONS
Although ventilation with high PEEP in ICU patients without ARDS may not reduce in-hospital mortality, the decreased incidences of ARDS and hypoxemia and the improvement in PaO/FIO were found in the high PEEP arm.
Topics: Hospital Mortality; Humans; Intensive Care Units; Positive-Pressure Respiration; Respiration, Artificial; Respiratory Distress Syndrome
PubMed: 34689064
DOI: 10.1016/j.jcrc.2021.09.026