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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 -
Asian Cardiovascular & Thoracic Annals Feb 2022There are various reports of air leaks with coronavirus disease 2019 (COVID-19). We undertook a systematic review of all published case reports and series to analyse the...
INTRODUCTION
There are various reports of air leaks with coronavirus disease 2019 (COVID-19). We undertook a systematic review of all published case reports and series to analyse the types of air leaks in COVID-19 and their outcomes.
METHODS
The literature search from PubMed, Science Direct, and Google Scholar databases was performed from the start of the pandemic till 31 March 2021. The inclusion criteria were case reports or series on (1) laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, (2) with the individual patient details, and (3) reported diagnosis of one or more air leak syndrome (pneumothorax, subcutaneous emphysema, pneumomediastinum, pneumoperitoneum, pneumopericardium).
RESULTS
A total of 105 studies with 188 patients were included in the final analysis. The median age was 56.02 (SD 15.53) years, 80% males, 11% had previous respiratory disease, and 8% were smokers. Severe or critical COVID-19 was present in 50.6% of the patients. Pneumothorax (68%) was the most common type of air leak. Most patients (56.7%) required intervention with lower mortality (29.1% vs. 44.1%, p = 0.07) and intercostal drain (95.9%) was the preferred interventional management. More than half of the patients developed air leak on spontaneous breathing. The mortality was significantly higher in patients who developed air leak with positive pressure ventilation (49%, p < 0.001) and required escalation of respiratory support (39%, p = 0.006).
CONCLUSION
Air leak in COVID-19 can occur spontaneously without positive pressure ventilation, higher transpulmonary pressures, and other risk factors like previous respiratory disease or smoking. The mortality is significantly higher if associated with positive pressure ventilation and escalation of respiratory support.
Topics: COVID-19; Female; Humans; Male; Mediastinal Emphysema; Middle Aged; Pneumothorax; SARS-CoV-2; Treatment Outcome
PubMed: 34247490
DOI: 10.1177/02184923211031134 -
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... Mar 2021In patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), mortality remains high. These patients require mechanical ventilation, which has... (Meta-Analysis)
Meta-Analysis
BACKGROUND
In patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), mortality remains high. These patients require mechanical ventilation, which has been associated with ventilator-induced lung injury. High levels of positive end-expiratory pressure (PEEP) could reduce this condition and improve patient survival. This is an updated version of the review first published in 2013.
OBJECTIVES
To assess the benefits and harms of high versus low levels of PEEP in adults with ALI and ARDS.
SEARCH METHODS
For our previous review, we searched databases from inception until 2013. For this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, and the Web of Science from inception until May 2020. We also searched for ongoing trials (www.trialscentral.org; www.clinicaltrial.gov; www.controlled-trials.com), and we screened the reference lists of included studies.
SELECTION CRITERIA
We included randomised controlled trials that compared high versus low levels of PEEP in ALI and ARDS participants who were intubated and mechanically ventilated in intensive care for at least 24 hours.
DATA COLLECTION AND ANALYSIS
Two review authors assessed risk of bias and extracted data independently. We contacted investigators to identify additional published and unpublished studies. We used standard methodological procedures expected by Cochrane.
MAIN RESULTS
We included four new studies (1343 participants) in this review update. In total, we included 10 studies (3851 participants). We found evidence of risk of bias in six studies, and the remaining studies fulfilled all criteria for low risk of bias. In eight studies (3703 participants), a comparison was made between high and low levels of PEEP, with the same tidal volume in both groups. In the remaining two studies (148 participants), the tidal volume was different between high- and low-level groups. In the main analysis, we assessed mortality occurring before hospital discharge only in studies that compared high versus low PEEP, with the same tidal volume in both groups. Evidence suggests that high PEEP may result in little to no difference in mortality compared to low PEEP (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.90 to 1.04; I² = 15%; 7 studies, 3640 participants; moderate-certainty evidence). In addition, high PEEP may result in little to no difference in barotrauma (RR 1.00, 95% CI 0.64 to 1.57; I² = 63%; 9 studies, 3791 participants; low-certainty evidence). High PEEP may improve oxygenation in patients up to the first and third days of mechanical ventilation (first day: mean difference (MD) 51.03, 95% CI 35.86 to 66.20; I² = 85%; 6 studies, 2594 participants; low-certainty evidence; third day: MD 50.32, 95% CI 34.92 to 65.72; I² = 83%; 6 studies, 2309 participants; low-certainty evidence) and probably improves oxygenation up to the seventh day (MD 28.52, 95% CI 20.82 to 36.21; I² = 0%; 5 studies, 1611 participants; moderate-certainty evidence). Evidence suggests that high PEEP results in little to no difference in the number of ventilator-free days (MD 0.45, 95% CI -2.02 to 2.92; I² = 81%; 3 studies, 1654 participants; low-certainty evidence). Available data were insufficient to pool the evidence for length of stay in the intensive care unit.
AUTHORS' CONCLUSIONS
Moderate-certainty evidence shows that high levels compared to low levels of PEEP do not reduce mortality before hospital discharge. Low-certainty evidence suggests that high levels of PEEP result in little to no difference in the risk of barotrauma. Low-certainty evidence also suggests that high levels of PEEP improve oxygenation up to the first and third days of mechanical ventilation, and moderate-certainty evidence indicates that high levels of PEEP improve oxygenation up to the seventh day of mechanical ventilation. As in our previous review, we found clinical heterogeneity - mainly within participant characteristics and methods of titrating PEEP - that does not allow us to draw definitive conclusions regarding the use of high levels of PEEP in patients with ALI and ARDS. Further studies should aim to determine the appropriate method of using high levels of PEEP and the advantages and disadvantages associated with high levels of PEEP in different ARDS and ALI patient populations.
Topics: Acute Disease; Adult; Bias; Humans; Intensive Care Units; Length of Stay; Oxygen Consumption; Positive-Pressure Respiration; Randomized Controlled Trials as Topic; Respiratory Distress Syndrome; Tidal Volume; Ventilator-Induced Lung Injury
PubMed: 33784416
DOI: 10.1002/14651858.CD009098.pub3 -
European Archives of... Feb 2022Tympanic membrane retraction (TMR) is a relatively common otological finding. However, no consensus on its management exists. We are looking especially for a treatment...
IMPORTANCE
Tympanic membrane retraction (TMR) is a relatively common otological finding. However, no consensus on its management exists. We are looking especially for a treatment strategy in the military population who are unable to attend frequent follow-up visits, and who experience relatively more barotrauma at great heights and depths and easily suffer from otitis externa from less hygienic circumstances.
OBJECTIVE
To assess and summarize the available evidence for the effectiveness of surgical interventions and watchful waiting policy in patients with a tympanic membrane retraction.
EVIDENCE REVIEW
The protocol for this systematic review was published at Prospero (207859). PubMed, Embase, and the Cochrane Database of Systematic Reviews were systematically searched from inception up to September 2020 for published and unpublished studies. We included randomized trials and observational studies that investigated surgical interventions (tympanoplasty, ventilation tube insertion) and wait-and-see policy. The primary outcomes of this study were clinical remission of the tympanic membrane retraction, tympanic membrane perforations and cholesteatoma development.
FINDINGS
In total, 27 studies were included, consisting of 1566 patients with TMRs. We included data from 2 randomized controlled trials (76 patients) and 25 observational studies (1490 patients). Seven studies (329 patients) investigated excision of the TMR with and without ventilation tube placement, 3 studies (207 patients) investigated the wait-and-see policy and 17 studies (1030 patients) investigated tympanoplasty for the treatment of TMRs.
CONCLUSIONS AND RELEVANCE
This study provides all the studies that have been published on the surgical management and wait-and-policy for tympanic membrane retractions. No high level of evidence comparative studies has been performed. The evidence for the management of tympanic membrane retractions is heterogenous and depends on many factors such as the patient population, location and severity of the TMR and presence of other ear pathologies (e.g., perforation, risk of cholesteatoma and serous otitis media).
Topics: Humans; Middle Ear Ventilation; Otitis Media with Effusion; Tympanic Membrane; Tympanoplasty
PubMed: 33689022
DOI: 10.1007/s00405-021-06719-3 -
The Cochrane Database of Systematic... Mar 2021High-flow nasal cannulae (HFNC) deliver high flows of blended humidified air and oxygen via wide-bore nasal cannulae and may be useful in providing respiratory support... (Meta-Analysis)
Meta-Analysis
BACKGROUND
High-flow nasal cannulae (HFNC) deliver high flows of blended humidified air and oxygen via wide-bore nasal cannulae and may be useful in providing respiratory support for adults experiencing acute respiratory failure, or at risk of acute respiratory failure, in the intensive care unit (ICU). This is an update of an earlier version of the review.
OBJECTIVES
To assess the effectiveness of HFNC compared to standard oxygen therapy, or non-invasive ventilation (NIV) or non-invasive positive pressure ventilation (NIPPV), for respiratory support in adults in the ICU.
SEARCH METHODS
We searched CENTRAL, MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane COVID-19 Register (17 April 2020), clinical trial registers (6 April 2020) and conducted forward and backward citation searches.
SELECTION CRITERIA
We included randomized controlled studies (RCTs) with a parallel-group or cross-over design comparing HFNC use versus other types of non-invasive respiratory support (standard oxygen therapy via nasal cannulae or mask; or NIV or NIPPV which included continuous positive airway pressure and bilevel positive airway pressure) in adults admitted to the ICU.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures as expected by Cochrane.
MAIN RESULTS
We included 31 studies (22 parallel-group and nine cross-over designs) with 5136 participants; this update included 20 new studies. Twenty-one studies compared HFNC with standard oxygen therapy, and 13 compared HFNC with NIV or NIPPV; three studies included both comparisons. We found 51 ongoing studies (estimated 12,807 participants), and 19 studies awaiting classification for which we could not ascertain study eligibility information. In 18 studies, treatment was initiated after extubation. In the remaining studies, participants were not previously mechanically ventilated. HFNC versus standard oxygen therapy HFNC may lead to less treatment failure as indicated by escalation to alternative types of oxygen therapy (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.45 to 0.86; 15 studies, 3044 participants; low-certainty evidence). HFNC probably makes little or no difference in mortality when compared with standard oxygen therapy (RR 0.96, 95% CI 0.82 to 1.11; 11 studies, 2673 participants; moderate-certainty evidence). HFNC probably results in little or no difference to cases of pneumonia (RR 0.72, 95% CI 0.48 to 1.09; 4 studies, 1057 participants; moderate-certainty evidence), and we were uncertain of its effect on nasal mucosa or skin trauma (RR 3.66, 95% CI 0.43 to 31.48; 2 studies, 617 participants; very low-certainty evidence). We found low-certainty evidence that HFNC may make little or no difference to the length of ICU stay according to the type of respiratory support used (MD 0.12 days, 95% CI -0.03 to 0.27; 7 studies, 1014 participants). We are uncertain whether HFNC made any difference to the ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO/FiO) within 24 hours of treatment (MD 10.34 mmHg, 95% CI -17.31 to 38; 5 studies, 600 participants; very low-certainty evidence). We are uncertain whether HFNC made any difference to short-term comfort (MD 0.31, 95% CI -0.60 to 1.22; 4 studies, 662 participants, very low-certainty evidence), or to long-term comfort (MD 0.59, 95% CI -2.29 to 3.47; 2 studies, 445 participants, very low-certainty evidence). HFNC versus NIV or NIPPV We found no evidence of a difference between groups in treatment failure when HFNC were used post-extubation or without prior use of mechanical ventilation (RR 0.98, 95% CI 0.78 to 1.22; 5 studies, 1758 participants; low-certainty evidence), or in-hospital mortality (RR 0.92, 95% CI 0.64 to 1.31; 5 studies, 1758 participants; low-certainty evidence). We are very uncertain about the effect of using HFNC on incidence of pneumonia (RR 0.51, 95% CI 0.17 to 1.52; 3 studies, 1750 participants; very low-certainty evidence), and HFNC may result in little or no difference to barotrauma (RR 1.15, 95% CI 0.42 to 3.14; 1 study, 830 participants; low-certainty evidence). HFNC may make little or no difference to the length of ICU stay (MD -0.72 days, 95% CI -2.85 to 1.42; 2 studies, 246 participants; low-certainty evidence). The ratio of PaO/FiO may be lower up to 24 hours with HFNC use (MD -58.10 mmHg, 95% CI -71.68 to -44.51; 3 studies, 1086 participants; low-certainty evidence). We are uncertain whether HFNC improved short-term comfort when measured using comfort scores (MD 1.33, 95% CI 0.74 to 1.92; 2 studies, 258 participants) and responses to questionnaires (RR 1.30, 95% CI 1.10 to 1.53; 1 study, 168 participants); evidence for short-term comfort was very low certainty. No studies reported on nasal mucosa or skin trauma.
AUTHORS' CONCLUSIONS
HFNC may lead to less treatment failure when compared to standard oxygen therapy, but probably makes little or no difference to treatment failure when compared to NIV or NIPPV. For most other review outcomes, we found no evidence of a difference in effect. However, the evidence was often of low or very low certainty. We found a large number of ongoing studies; including these in future updates could increase the certainty or may alter the direction of these effects.
Topics: Acute Disease; Adult; Barotrauma; Bias; Critical Care; Hospital Mortality; Humans; Intubation; Length of Stay; Masks; Nasal Mucosa; Noninvasive Ventilation; Oxygen Inhalation Therapy; Patient Reported Outcome Measures; Pneumonia; Randomized Controlled Trials as Topic; Respiration, Artificial; Respiratory Insufficiency; Treatment Failure
PubMed: 33661521
DOI: 10.1002/14651858.CD010172.pub3 -
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 -
Intensive Care Medicine Experimental Dec 2020In patients with acute respiratory distress syndrome (ARDS), lung recruitment could be maximised with the use of recruitment manoeuvres (RM) or applying a positive... (Review)
Review
Effects of higher PEEP and recruitment manoeuvres on mortality in patients with ARDS: a systematic review, meta-analysis, meta-regression and trial sequential analysis of randomized controlled trials.
PURPOSE
In patients with acute respiratory distress syndrome (ARDS), lung recruitment could be maximised with the use of recruitment manoeuvres (RM) or applying a positive end-expiratory pressure (PEEP) higher than what is necessary to maintain minimal adequate oxygenation. We aimed to determine whether ventilation strategies using higher PEEP and/or RMs could decrease mortality in patients with ARDS.
METHODS
We searched MEDLINE, EMBASE and CENTRAL from 1996 to December 2019, included randomized controlled trials comparing ventilation with higher PEEP and/or RMs to strategies with lower PEEP and no RMs in patients with ARDS. We computed pooled estimates with a DerSimonian-Laird mixed-effects model, assessing mortality and incidence of barotrauma, population characteristics, physiologic variables and ventilator settings. We performed a trial sequential analysis (TSA) and a meta-regression.
RESULTS
Excluding two studies that used tidal volume (V) reduction as co-intervention, we included 3870 patients from 10 trials using higher PEEP alone (n = 3), combined with RMs (n = 6) or RMs alone (n = 1). We did not observe differences in mortality (relative risk, RR 0.96, 95% confidence interval, CI [0.84-1.09], p = 0.50) nor in incidence of barotrauma (RR 1.22, 95% CI [0.93-1.61], p = 0.16). In the meta-regression, the PEEP difference between intervention and control group at day 1 and the use of RMs were not associated with increased risk of barotrauma. The TSA reached the required information size for mortality (n = 2928), and the z-line surpassed the futility boundary.
CONCLUSIONS
At low V, the routine use of higher PEEP and/or RMs did not reduce mortality in unselected patients with ARDS.
TRIAL REGISTRATION
PROSPERO CRD42017082035 .
PubMed: 33336325
DOI: 10.1186/s40635-020-00322-2 -
Intensive Care Medicine Experimental Oct 2020Existing clinical practice guidelines support the use of neuromuscular blocking agents (NMBA) in acute respiratory distress syndrome (ARDS); however, a recent large... (Review)
Review
PURPOSE
Existing clinical practice guidelines support the use of neuromuscular blocking agents (NMBA) in acute respiratory distress syndrome (ARDS); however, a recent large randomized clinical trial (RCT) has questioned this practice. Therefore, we updated a previous systematic review to determine the efficacy and safety of NMBAs in ARDS.
METHODS
We searched MEDLINE, EMBASE (October 2012 to July 2019), the Cochrane (Central) database, and clinical trial registries ( ClinicalTrials.gov , ISRCTN Register, and WHO ICTRP) for RCTs comparing the effects of NMBA as a continuous infusion versus placebo or no NMBA infusion (but allowing intermittent NMBA boluses) on patient-important outcomes for adults with ARDS. Two independent reviewers assessed the methodologic quality of the primary studies and abstracted data.
RESULTS
Seven RCTs, including four new RCTs, met eligibility criteria for this review. These trials enrolled 1598 patients with moderate to severe ARDS at centers in the USA, France, and China. All trials assessed short-term continuous infusions of cisatracurium or vecuronium. The pooled estimate for mortality outcomes showed significant statistical heterogeneity, which was only explained by a subgroup analysis by depth of sedation in the control arm. A continuous NMBA infusion did not improve mortality when compared to a light sedation strategy with no NMBA infusion (relative risk [RR] 0.99; 95% CI 0.86-1.15; moderate certainty; P = 0.93). On the other hand, continuous NMBA infusion reduced mortality when compared to deep sedation with as needed NMBA boluses (RR 0.71; 95% CI 0.57-0.89; low certainty; P = 0.003). Continuous NMBA infusion reduced the rate of barotrauma (RR 0.55; 95% CI 0.35-0.85, moderate certainty; P = 0.008) across eligible trials, but the effect on ventilator-free days, duration of mechanical ventilation, and ICU-acquired weakness was uncertain.
CONCLUSIONS
Inconsistency in study methods and findings precluded the pooling of all trials for mortality. In a pre-planned sensitivity analysis, the impact of NMBA infusion on mortality depends on the strategy used in the control arm, showing reduced mortality when compared to deep sedation, but no effect on mortality when compared to lighter sedation. In both situations, a continuous NMBA infusion may reduce the risk of barotrauma, but the effects on other patient-important outcomes remain unclear. Future research, including an individual patient data meta-analysis, could help clarify some of the observed findings in this updated systematic review.
PubMed: 33095344
DOI: 10.1186/s40635-020-00348-6 -
Respiratory Care Jan 2021Studies evaluating neuromuscular blocking agents (NMBAs) in the management of ARDS have produced inconsistent results in terms of their effect on mortality. The purpose... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Studies evaluating neuromuscular blocking agents (NMBAs) in the management of ARDS have produced inconsistent results in terms of their effect on mortality. The purpose of this systematic review and meta-analysis was to evaluate differences in mortality comparing subjects with ARDS who received NMBA to those who received placebo or usual care.
METHODS
We searched Ovid, MEDLINE, Embase, CINAHL, Cochrane, Scopus, and Web of Science for randomized controlled trials evaluating administration of NMBAs in subjects with ARDS.
RESULTS
We included 6 studies ( = 1,558 subjects) from 1,814 abstracts identified by our search strategy. The use of early, continuous-infusion NMBAs reduces the risk of short-term (ie, 21-28-d) mortality (relative risk 0.71 [95% CI 0.52-0.98], = .030, = 60%) in subjects with ARDS but does not reduce the risk of long-term (ie, 90-d) mortality (relative risk 0.81 [95% CI 0.64-1.04], = .10, = 54%). NMBAs decreased the risk of barotrauma (relative risk 0.55 [95% CI 0.35-0.85], = .008, = 0%) and pneumothorax (relative risk 0.46 [95% CI 0.28-0.77], = .003, = 0%) compared to control.
CONCLUSIONS
In subjects with ARDS, early use of NMBAs improves oxygenation, reduces the incidence of ventilator-induced lung injury, and decreases 21-28-d mortality, but it does not improve 90-d mortality. NMBAs should be considered for select patients with moderate-to-severe ARDS for short durations.
Topics: Barotrauma; Humans; Lung; Neuromuscular Blocking Agents; Respiration, Artificial; Respiratory Distress Syndrome; Time Factors
PubMed: 32843506
DOI: 10.4187/respcare.07849