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JBI Database of Systematic Reviews and... May 2018To determine the effects of dexmedetomidine versus propofol on extubation time, intensive care unit (ICU) length of stay, total hospital length of stay and in-hospital...
Effectiveness of dexmedetomidine versus propofol on extubation times, length of stay and mortality rates in adult cardiac surgery patients: a systematic review and meta-analysis.
OBJECTIVE
To determine the effects of dexmedetomidine versus propofol on extubation time, intensive care unit (ICU) length of stay, total hospital length of stay and in-hospital mortality rates in cardiac surgery patients.
INTRODUCTION
Recovery from cardiovascular surgery involves weaning from mechanical ventilation. Mechanical ventilation decreases the work of breathing for patients by inhaling oxygen and exhaling carbon dioxide via a ventilator or breathing machine. Prolonged mechanical ventilation is associated with complications, such as pneumonia and lung injury, and increases the risk of morbidity and mortality. Major risk factors that contribute to lung injury are due to high tidal volumes and barotrauma. Cardiac surgery patients remain on the ventilator postoperatively due to the high dose opioid-based anesthesia and the initial vulnerable hemodynamic state. An important component of postoperative management following cardiac surgery is the use of sedation to reduce the stress response, facilitate assisted ventilation, and provide anxiolysis. Propofol and dexmedetomidine are two common sedative agents with differing pharmacological profiles used to provide comfort and minimize hemodynamic disturbances during this recovery phase. Choice of drug may have an impact on length of mechanical ventilation, length of stay and mortality.
INCLUSION CRITERIA
Participants included were ≥18 years, of any gender or ethnicity, undergoing valvular surgery, coronary artery bypass graft (CABG) surgery, or valvular surgery and CABG. Studies were excluded if participants received both dexmedetomidine and propofol concurrently as a primary sedative. Interventions were propofol compared to dexmedetomidine as continuous infusions for sedation after cardiac surgery. All variations of dosages and duration of both sedative agents were included. Outcomes of interest were: total time (hours) of mechanical ventilation after cardiac surgery, specifically from end of surgery to extubation; total length of stay (LOS) in the ICU (hours) following cardiac surgery, specifically from ICU admission to transfer to medical ward; total hospital LOS (hours) following cardiac surgery, from date of admission to date of discharge; and in-hospital mortality rates, from date of admission to date of discharge. Randomized controlled trials (RCTs), controlled trials, and prospective and retrospective cohort studies were considered for inclusion.
METHODS
A search was conducted in MEDLINE via PubMed, Embase, Trip Database, ProQuest Nursing and Allied Health Source Database, Web of Science, ProQuest Dissertations and Theses Global, and MedNar to locate both published and unpublished studies between January 1, 1999 and November 23, 2017. Two reviewers assessed the methodological quality using standardized critical appraisal instruments from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Quantitative data were extracted using the standardized data extraction tool from JBI SUMARI. Data were pooled using Comprehensive Meta-Analysis Software Version 3 (Biostat, NJ, USA). Mean differences (95% confidence interval [CI]) and effect size estimates were calculated for continuous outcomes. Meta-analysis using a random-effects model was performed for length of mechanical ventilation, ICU LOS, and hospital LOS. Results have been presented in narrative form when findings could not be pooled using meta-analysis. Standard GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) evidence assessment of outcomes has been reported.
RESULTS
A total of four studies were included in the review. Meta-analysis of three cohort studies revealed dexmedetomidine to be superior to propofol with an average reduction of 4.18 hours (95% CI -6.69 to -1.67, p = 0.001) on the extubation times, an average 9.89 hour (95% CI -18.6 to -1.19, p = 0.03) reduction in ICU LOS, and an average 37.9 hour (95% CI, -60.41 to -15.46, p = 0.00) reduction in overall hospital LOS. A RCT was excluded from pooling for meta-analysis, but its results were congruent with meta-analysis results. There was lack of sufficient data to perform meta-analysis on in-hospital mortality rates.
CONCLUSIONS
In postoperative cardiac surgery patients, dexmedetomidine is associated with a shorter time to extubation, shorter ICU LOS, and shorter hospital LOS in postoperative cardiac surgery patients compared to propofol. The quality of evidence for these findings however is low and no recommendations can be made to change current practice. There was insufficient evidence to determine significant differences in-hospital mortality rates. Sedation protocols still need to be formulated.There are significant gaps in the literature. Areas of further research include additional well-designed and appropriately powered RCTs with wide inclusion criteria to reflect this surgical population; quantitative, transparent, and standardized sedation, weaning, and extubation protocols; precise and standardized methods and measurements for interventions and outcomes, and short- and long-term morbidity and mortality follow-up.
Topics: Adult; Airway Extubation; Analgesics, Non-Narcotic; Anesthetics, Intravenous; Cardiac Surgical Procedures; Critical Care; Dexmedetomidine; Hospital Mortality; Humans; Intensive Care Units; Length of Stay; Propofol; Respiration, Artificial; Time Factors
PubMed: 29762314
DOI: 10.11124/JBISRIR-2017-003488 -
Otology & Neurotology : Official... Jun 2018To conduct a systematic review of the published evidence relating to the prevention of otic barotrauma in aviation. In particular, this review sought to identify...
OBJECTIVE
To conduct a systematic review of the published evidence relating to the prevention of otic barotrauma in aviation. In particular, this review sought to identify procedures, techniques, devices, and medications for the prevention of otic barotrauma as well as evaluate the evidence relating to their efficacy.
DATA SOURCES
Ten databases including Embase, MEDLINE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched using the full historical range.
STUDY SELECTION
English language articles including more than or equal to five participants or cases were included. Outcomes of interest were reduced severity or the successful prevention of otic barotrauma in participants undergoing gradual changes in pressure during air travel or its simulation.
DATA EXTRACTION
Articles and data were extracted and analyzed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses and other international guidelines.
CONCLUSIONS
This review highlights the lack of published evidence relating to what is a significant and increasingly common problem in otology. There is level 1 evidence that supports the efficacy of oral pseudoephedrine (120 mg) in preventing otic barotrauma in adults. However, oral pseudoephedrine (1 mg/kg) does not appear to be effective in children. There is insufficient evidence to support the efficacy of either nasal balloon inflation or pressure-equalizing ear plugs for the prevention of otic barotrauma. A recently reported, novel technique for insertion of temporary tympanostomy tubes is promising but requires further evaluation.
Topics: Adult; Aerospace Medicine; Air Travel; Barotrauma; Child; Humans
PubMed: 29595579
DOI: 10.1097/MAO.0000000000001779 -
Otology & Neurotology : Official... Feb 2018Baro-challenge-induced Eustachian tube dysfunction (baro-induced ETD) is characterized by failure of the Eustachian tube (ET) to open adequately to permit middle-ear...
OBJECTIVES
Baro-challenge-induced Eustachian tube dysfunction (baro-induced ETD) is characterized by failure of the Eustachian tube (ET) to open adequately to permit middle-ear pressure regulation during ambient pressure changes. There are no well-characterized tests for identifying the condition, which makes both patient diagnosis and research into treatment efficacy challenging. This systematic review evaluates ET function tests as potential outcome measures for baro-induced ETD.
DATA SOURCES
MEDLINE and CENTRAL were searched (database inception to March 2017) and reference lists reviewed for all relevant English Language articles.
STUDY SELECTION
Tests in included studies were required to measure ET function in patients reporting baro-induced ear symptoms or barotrauma.
DATA EXTRACTION
Data were extracted in a standardized manner, and studies assessed according to Standards for Reporting of Diagnostic Accuracy Studies (STARD) criteria. The primary outcome of interest was the accuracy of ET function tests.
DATA SYNTHESIS
Heterogeneity of subject demographics, ET function test methodology, and reference standards only permitted narrative systematic review.
CONCLUSION
Sixteen studies involving seven different types of ET function tests were identified. The nine-step test was the most commonly used outcome measure, with overall test sensitivity and specificity ranges of 37 to 100% and 57 to 100%, respectively. Tympanometry test sensitivity was consistently poor (0-50%) while specificity was higher (52-97%). Published accuracy data for other ET function tests and test combinations were limited. Currently, no single test can be recommended for use in clinical practice. A combination of the nine-step test with other objective tests or patient-reported measures appears most promising as a core set of outcome measures for baro-induced ETD.
Topics: Diagnostic Techniques, Otological; Ear Diseases; Eustachian Tube; Female; Humans; Sensitivity and Specificity
PubMed: 29315176
DOI: 10.1097/MAO.0000000000001666 -
The Cochrane Database of Systematic... Dec 2017Acute respiratory failure is a common life-threatening complication of acute onset neuromuscular diseases, and may exacerbate chronic hypoventilation in patients with... (Review)
Review
BACKGROUND
Acute respiratory failure is a common life-threatening complication of acute onset neuromuscular diseases, and may exacerbate chronic hypoventilation in patients with neuromuscular disease or chest wall disorders. Standard management includes oxygen supplementation, physiotherapy, cough assistance, and, whenever needed, antibiotics and intermittent positive pressure ventilation. Non-invasive mechanical ventilation (NIV) via nasal, buccal or full-face devices has become routine practice in many centres.
OBJECTIVES
The primary objective of this review was to compare the efficacy of non-invasive ventilation with invasive ventilation in improving short-term survival in acute respiratory failure in people with neuromuscular disease and chest wall disorders. The secondary objectives were to compare the effects of NIV with those of invasive mechanical ventilation on improvement in arterial blood gas after 24 hours and lung function measurements after one month, incidence of barotrauma and ventilator-associated pneumonia, duration of mechanical ventilation, length of stay in the intensive care unit and length of hospital stay.
SEARCH METHODS
We searched the following databases on 11 September 2017: the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE and Embase. We also searched conference proceedings and clinical trials registries.
SELECTION CRITERIA
We planned to include randomised or quasi-randomised trials with or without blinding. We planned to include trials performed in children or adults with acute onset neuromuscular diseases or chronic neuromuscular disease or chest wall disorders presenting with acute respiratory failure that compared the benefits and risks of invasive ventilation versus NIV.
DATA COLLECTION AND ANALYSIS
Two review authors reviewed searches and independently selected studies for assessment. We planned to follow standard Cochrane methodology for data collection and analysis.
MAIN RESULTS
We did not identify any trials eligible for inclusion in the review.
AUTHORS' CONCLUSIONS
Acute respiratory failure is a life-threatening complication of acute onset neuromuscular disease and of chronic neuromuscular disease and chest wall disorders. We found no randomised trials on which to elaborate evidence-based practice for the use of non-invasive versus invasive mechanical ventilation. For researchers, there is a need to design and conduct new randomised trials to compare NIV with invasive ventilation in acute neuromuscular respiratory failure. These trials should anticipate variations in treatment responses according to disease condition (acute onset versus acute exacerbation on chronic neuromuscular diseases) and according to the presence or absence of bulbar dysfunction.
Topics: Acute Disease; Humans; Neuromuscular Diseases; Noninvasive Ventilation; Respiration, Artificial; Respiratory Insufficiency; Thoracic Wall
PubMed: 29199768
DOI: 10.1002/14651858.CD008380.pub2 -
The Cochrane Database of Systematic... Oct 2017Effective synchronisation of infant respiratory effort with mechanical ventilation may allow adequate gas exchange to occur at lower peak airway pressures, potentially... (Review)
Review
BACKGROUND
Effective synchronisation of infant respiratory effort with mechanical ventilation may allow adequate gas exchange to occur at lower peak airway pressures, potentially reducing barotrauma and volutrauma and development of air leaks and bronchopulmonary dysplasia. During neurally adjusted ventilatory assist ventilation (NAVA), respiratory support is initiated upon detection of an electrical signal from the diaphragm muscle, and pressure is provided in proportion to and synchronous with electrical activity of the diaphragm (EADi). Compared to other modes of triggered ventilation, this may provide advantages in improving synchrony.
OBJECTIVES
Primary• To determine whether NAVA, when used as a primary or rescue mode of ventilation, results in reduced rates of bronchopulmonary dysplasia (BPD) or death among term and preterm newborn infants compared to other forms of triggered ventilation• To assess the safety of NAVA by determining whether it leads to greater risk of intraventricular haemorrhage (IVH), periventricular leukomalacia, or air leaks when compared to other forms of triggered ventilation Secondary• To determine whether benefits of NAVA differ by gestational age (term or preterm)• To determine whether outcomes of cross-over trials performed during the first two weeks of life include peak pressure requirements, episodes of hypocarbia or hypercarbia, oxygenation index, and the work of breathing SEARCH METHODS: We performed searches of the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cohrane Library; MEDLINE via Ovid SP (January 1966 to March 2017); Embase via Ovid SP (January 1980 to March 2017); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host (1982 to March 2017); and the Web of Science (1985 to 2017). We searched abstracts from annual meetings of the Pediatric Academic Societies (PAS) (2000 to 2016); meetings of the European Society of Pediatric Research (published in Pediatric Research); and meetings of the Perinatal Society of Australia and New Zealand (PSANZ) (2005 to 2016). We also searched clinical trials databases to March 2017.
SELECTION CRITERIA
We included randomised and quasi-randomised clinical trials including cross-over trials comparing NAVA with other modes of triggered ventilation (assist control ventilation (ACV),synchronous intermittent mandatory ventilation plus pressure support (SIMV ± PS), pressure support ventilation (PSV), or proportional assist ventilation (PAV)) used in neonates.
DATA COLLECTION AND ANALYSIS
Primary outcomes of interest from randomised controlled trials were all-cause mortality, bronchopulmonary dysplasia (BPD; defined as oxygen requirement at 28 days), and a combined outcome of all-cause mortality or BPD. Secondary outcomes were duration of mechanical ventilation, incidence of air leak, incidence of IVH or periventricular leukomalacia, and survival with an oxygen requirement at 36 weeks' postmenstrual age.Outcomes of interest from cross-over trials were maximum fraction of inspired oxygen, mean peak inspiratory pressure, episodes of hypocarbia, and episodes of hypercarbia measured across the time period of each arm of the cross-over. We planned to assess work of breathing; oxygenation index, and thoraco-abdominal asynchrony at the end of the time period of each arm of the cross-over study.
MAIN RESULTS
We included one randomised controlled study comparing NAVA versus patient-triggered time-cycled pressure-limited ventilation. This study found no significant difference in duration of mechanical ventilation, nor in rates of BPD, pneumothorax, or IVH.
AUTHORS' CONCLUSIONS
Risks and benefits of NAVA compared to other forms of ventilation for neonates are uncertain. Well-designed trials are required to evaluate this new form of triggered ventilation.
Topics: Bronchopulmonary Dysplasia; Cerebral Intraventricular Hemorrhage; Humans; Infant, Newborn; Interactive Ventilatory Support; Leukomalacia, Periventricular; Respiratory Mechanics
PubMed: 29077984
DOI: 10.1002/14651858.CD012251.pub2 -
Annals of the American Thoracic Society Oct 2017In patients with acute respiratory distress syndrome (ARDS), lung recruitment maneuvers (LRMs) may prevent ventilator-induced lung injury and improve survival. (Meta-Analysis)
Meta-Analysis Review
RATIONALE
In patients with acute respiratory distress syndrome (ARDS), lung recruitment maneuvers (LRMs) may prevent ventilator-induced lung injury and improve survival.
OBJECTIVES
To summarize the current evidence in support of the use of LRMs in adult patients with ARDS and to inform the recently published American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline on mechanical ventilation in ARDS.
METHODS
We conducted a systematic review and meta-analysis of randomized trials comparing mechanical ventilation strategies with and without LRMs. Eligible trials were identified from among previously published systematic reviews and an updated literature search. Data on 28-day mortality, oxygenation, adverse events, and use of rescue therapy were collected, and results were pooled using random effects models weighted by inverse variance. Strength of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation methodology.
RESULTS
We screened 430 citations and previous systematic reviews and found six trials eligible for inclusion (n = 1,423 patients in total). The type of LRM varied widely between trials, and five of the trials involved a cointervention with a higher positive end-expiratory pressure (PEEP) ventilation strategy. Risk of bias was deemed high in one trial. In the primary analysis, the only trial without a cointervention showed that LRMs were associated with reduced mortality (one trial; risk ratio [RR], 0.62; 95% confidence interval [CI], 0.39-0.98; evidence grade = low). Meta-analysis of all six trials also suggested a significant mortality reduction (six trials; RR, 0.81; 95% CI, 0.69-0.95; evidence grade = moderate), and the use of a higher PEEP cointervention did not significantly modify the mortality effect (P = 0.27 for heterogeneity). LRMs were also associated with improved oxygenation after 24 hours (six trials; mean increase, 52 mm Hg; 95% CI, 23-81 mm Hg) and less frequent requirement for rescue therapy (three trials; RR, 0.65; 95% CI, 0.45-0.94). LRMs were not associated with an increased rate of barotrauma (four trials; RR, 0.84; 95% CI, 0.46-1.55). The rate of hemodynamic compromise was not significantly increased with LRMs (three trials; RR, 1.30; 95% CI, 0.92-1.78).
CONCLUSIONS
Randomized trials suggest that LRMs in combination with a higher PEEP ventilation strategy reduce mortality, but confidence in this finding is limited. Further trials are required to confirm benefit from LRMs in adults with ARDS.
Topics: Adult; Humans; Lung Compliance; Positive-Pressure Respiration; Randomized Controlled Trials as Topic; Respiratory Distress Syndrome; Ventilator-Induced Lung Injury
PubMed: 29043837
DOI: 10.1513/AnnalsATS.201704-340OT -
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 -
Annals of the American Thoracic Society Oct 2017By minimizing tidal lung strain and maintaining alveolar recruitment, high-frequency oscillatory ventilation (HFOV) may protect against ventilator-induced lung injury. (Meta-Analysis)
Meta-Analysis Review
RATIONALE
By minimizing tidal lung strain and maintaining alveolar recruitment, high-frequency oscillatory ventilation (HFOV) may protect against ventilator-induced lung injury.
OBJECTIVES
To summarize the current evidence in support of the use of HFOV in adult patients with acute respiratory distress syndrome.
METHODS
We conducted a systematic review and meta-analysis of randomized trials comparing mortality rates with the use of HFOV versus conventional mechanical ventilation for adult patients with acute respiratory distress syndrome. Eligible trials were identified from previously published systematic reviews and an updated literature search. Data on 28-day mortality, oxygenation, adverse events, and use of rescue therapies were collected; effects were pooled using random effects models weighted by inverse variance. Strength of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation methodology.
RESULTS
Six trials were eligible for inclusion (total n = 1,715 patients). Four trials mandated lung-protective ventilation in the control group and one trial applied a higher positive end-expiratory pressure (PEEP) ventilation strategy in the control group. None of the trials were judged to be at high risk of bias, though all were unblinded. In trials that did not systematically employ any cointerventions with HFOV and that targeted low tidal volumes in the patients randomized to conventional ventilation (primary analysis), HFOV had no significant effect on mortality (three trials; risk ratio [RR], 1.14; 95% confidence interval [CI], 0.88 to 1.48; evidence grade = high). Pooled analysis of all six trials also did not suggest a significant mortality reduction (RR, 0.94; 95% CI, 0.71 to 1.24; evidence grade = low). The single trial that employed a conventional ventilation strategy with both lower tidal volumes and higher PEEP as control reported higher mortality in patients receiving HFOV (RR, 1.41; 95% CI, 1.12 to 1.79). HFOV was not associated with improved oxygenation after 24 hours (five trials; mean increase of 10 mm Hg; 95% CI, -16 to 37 mm Hg). Rates of barotrauma were not different between HFOV and conventional ventilation, although significant benefit or harm could not be excluded (RR, 1.15; 95% CI, 0.61 to 2.17).
CONCLUSIONS
Published randomized trials suggest that HFOV is not associated with a mortality benefit, and may even be harmful in comparison to ventilation with low tidal volumes and higher levels of PEEP.
Topics: Adult; High-Frequency Ventilation; Humans; Positive-Pressure Respiration; Randomized Controlled Trials as Topic; Respiratory Distress Syndrome; Tidal Volume; Ventilator-Induced Lung Injury
PubMed: 29043832
DOI: 10.1513/AnnalsATS.201704-341OT -
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 -
The Journal of Headache and Pain Aug 2017Headache attributed to airplane travel, also named "airplane headache" (AH) is a headache that occurs during take-off and landing. Today, there are still uncertainties... (Review)
Review
BACKGROUND
Headache attributed to airplane travel, also named "airplane headache" (AH) is a headache that occurs during take-off and landing. Today, there are still uncertainties about the pathophysiology and treatment of AH. This systematic review was performed to facilitate identification of the existing literature on AH in order to discuss the current evidence and areas that remain to be investigated in AH.
METHODS
The systematic literature search was performed in 3 relevant medical databases; PubMed, Scopus, and Embase. The search yielded 220 papers and the papers were sorted based on inclusion and exclusion criteria established for this study.
RESULTS
This systematic review included 39 papers. Main findings revealed that AH attacks are clinically stereotyped and appear mostly during landing phases. The headache presents as a severe painful headache that often disappears within 30 min. The pain is unilateral and localized in the fronto-orbital region. Sinus barotrauma has been considered as the main cause of AH. Nonsteroidal anti-inflammatory drugs and triptans have been taken by passengers with AH, to relieve the headache.
CONCLUSIONS
Based on this systematic review, further studies seem required to investigate underlying mechanisms in AH and also to investigate the biological effects of nonsteroidal anti-inflammatory drugs and triptans for alleviating of AH. These studies would advance our understanding of AH pathogenesis and potential use of treatments that are not yet established.
Topics: Aircraft; Anti-Inflammatory Agents, Non-Steroidal; Barotrauma; Frontal Sinus; Headache; Humans; Travel; Tryptamines
PubMed: 28815436
DOI: 10.1186/s10194-017-0788-0