scholarly journals Higher Versus Lower Positive End-Expiratory Pressure in Patients Without Acute Respiratory Distress Syndrome: A Meta-Analysis of Randomized Controlled Trials

2021 ◽  
Author(s):  
Tommaso Pettenuzzo ◽  
Annalisa Boscolo ◽  
Alessandro De Cassai ◽  
Nicolò Sella ◽  
Francesco Zarantonello ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Hospital Mortality ◽  
Distress Syndrome ◽  
Meta Analysis ◽  
Invasive Mechanical Ventilation ◽  
Controlled Trials ◽  
Positive End Expiratory Pressure ◽  
Randomized Controlled ◽  
Duration Of Ventilation

Abstract Background: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the association of higher positive end-expiratory pressure (PEEP), as opposed to lower PEEP, with hospital mortality in adult intensive care unit (ICU) patients undergoing invasive mechanical ventilation for reasons other than acute respiratory distress syndrome (ARDS). Methods: We performed an electronic search of MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science from inception until December 18, 2020 with no language restrictions. In addition, a research-in-progress database and grey literature were searched. Results: We identified 22 RCTs (2225 patients) comparing higher PEEP (1007 patients) with lower PEEP (991 patients). No statistically significant association between higher PEEP and hospital mortality was observed (risk ratio 1.02, 95% confidence interval 0.89-1.16; I2 = 0%, p = 0.62; low certainty of evidence). Among secondary outcomes, higher PEEP was associated with better oxygenation, higher respiratory system compliance, and lower risk of hypoxemia and ARDS occurrence. Furthermore, barotrauma, hypotension, duration of ventilation, lengths of stay, and ICU mortality were similar between the two groups. Conclusions: In our meta-analysis of RCTs, higher PEEP, compared with lower PEEP, was not associated with mortality or duration of ventilation in patients without ARDS receiving invasive mechanical ventilation, despite being associated with improved oxygenation and lower occurrence of ARDS.

scholarly journals Higher versus lower positive end-expiratory pressure in patients without acute respiratory distress syndrome: a meta-analysis of randomized controlled trials

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Tommaso Pettenuzzo ◽  
Annalisa Boscolo ◽  
Alessandro De Cassai ◽  
Nicolò Sella ◽  
Francesco Zarantonello ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Hospital Mortality ◽  
Respiratory Distress Syndrome ◽  
Distress Syndrome ◽  
Meta Analysis ◽  
Invasive Mechanical Ventilation ◽  
Controlled Trials ◽  
Positive End Expiratory Pressure ◽  
Randomized Controlled

Abstract Background We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the association of higher positive end-expiratory pressure (PEEP), as opposed to lower PEEP, with hospital mortality in adult intensive care unit (ICU) patients undergoing invasive mechanical ventilation for reasons other than acute respiratory distress syndrome (ARDS). Methods We performed an electronic search of MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science from inception until June 16, 2021 with no language restrictions. In addition, a research-in-progress database and grey literature were searched. Results We identified 22 RCTs (2225 patients) comparing higher PEEP (1007 patients) with lower PEEP (991 patients). No statistically significant association between higher PEEP and hospital mortality was observed (risk ratio 1.02, 95% confidence interval 0.89–1.16; I2 = 0%, p = 0.62; low certainty of evidence). Among secondary outcomes, higher PEEP was associated with better oxygenation, higher respiratory system compliance, and lower risk of hypoxemia and ARDS occurrence. Furthermore, barotrauma, hypotension, duration of ventilation, lengths of stay, and ICU mortality were similar between the two groups. Conclusions In our meta-analysis of RCTs, higher PEEP, compared with lower PEEP, was not associated with mortality in patients without ARDS receiving invasive mechanical ventilation. Further large high-quality RCTs are required to confirm these findings.

scholarly journals Efficacy of airway pressure release ventilation for acute respiratory distress syndrome: A meta-analysis

2020 ◽  
Author(s):  
Zhen Junhai ◽  
Hu Bangchuan ◽  
Gong Shijin ◽  
Yu Yihua ◽  
Yan Jing ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Airway Pressure ◽  
Distress Syndrome ◽  
Meta Analysis ◽  
Conventional Mechanical Ventilation ◽  
Controlled Trials ◽  
Randomized Controlled ◽  
Pressure Release Ventilation

Abstract Background Airway pressure release ventilation (APRV) has been described many years, however, it is still unclear whether APRV improves outcomes in critically ill patients admitted to Intensive Care Unit with acute respiratory distress syndrome (ARDS). Methods 3 databases were searched for randomized controlled trials (RCTs) until 8 August 2019. The relative risk (RR), mean difference (MD) and 95% confidence intervals (CI) were determined. Results A total of six randomized controlled trials (RCTs) were included with 360 ARDS patients. The Meta analysis showed that the mean arterial pressure (MAP) in APRV group is higher than traditional mechanical ventilation group [MD = 2.35, 95% CI=(1.05,3.64), P = 0.0004], and the airway peak pressure (Ppeak) is lower in APRV group with statistical difference [MD=-2.04,95% CI=(-3.33,-0.75), P = 0.002]. However, no significant beneficial effect on oxygen index (PaO2/FiO2) was shown between two groups (MD = 26.24, 95% CI=(-26.50,78.97), P = 0.33). Compared with conventional mechanical ventilation, APRV significantly improved 28-day mortality [RR = 0.66, 95% CI=(0.47,0.94), P = 0.02]. Conclusions For critically ill patients with ARDS, application of APRV is associated with the increase of MAP, the reduction of the airway Ppeak and 28-day mortality, while there is no sufficient evidence to support the APRV is superior to conventional mechanical ventilation in PaO2/FiO2.

scholarly journals Optimal Positive End Expiratory Pressure Levels in Ventilated Patients Without Acute Respiratory Distress Syndrome: A Bayesian Network Meta-Analysis and Systematic Review of Randomized Controlled Trials

2021 ◽  
Vol 8 ◽  
Author(s):  
Jing Zhou ◽  
Zhimin Lin ◽  
Xiumei Deng ◽  
Baiyun Liu ◽  
Yu Zhang ◽  
...  
Keyword(s):  
Systematic Review ◽  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Meta Analysis ◽  
Controlled Trials ◽  
Positive End Expiratory Pressure ◽  
Randomized Controlled ◽  
Ventilated Patients

Background: To find the optimal positive end expiratory pressure (PEEP) in mechanical ventilated patients without Acute Respiratory Distress Syndrome (ARDS), we conducted a Bayesian network meta-analysis and systematic review of randomized controlled trials (RCTs) comparing different level of PEEP based on a novel classification of PEEP level: ZEEP group (PEEP = 0 cm H2O); lower PEEP group (PEEP = 1–6 cm H2O); intermediate PEEP group (PEEP = 7–10 cm H2O); higher PEEP group (PEEP > 10 cm H2O).Result: Twenty eight eligible studies with 2,712 patients were included. There were no significant differences in the duration of mechanical ventilation between higher and intermediate PEEP (MD: 0.020, 95% CI: −0.14, 0.28), higher and lower PEEP (MD: −0.010, 95% CI: −0.23, 0.22), higher PEEP and ZEEP (MD: 0.010, 95% CI: −0.40, 0.22), intermediate and lower PEEP (MD: −0.040, 95% CI: −0.18, 0.040), intermediate PEEP and ZEEP (MD: −0.010, 95% CI: −0.42, 0.10), lower PEEP and ZEEP (MD: 0.020, 95% CI: −0.32, 0.13), respectively. Higher PEEP was associated with significantly higher PaO2/FiO2 ratio(PFR) when compared to ZEEP (MD: 73.24, 95% CI: 11.03, 130.7), and higher incidence of pneumothorax when compared to intermediate PEEP, lower PEEP and ZEEP (OR: 2.91e + 12, 95% CI: 40.3, 1.76e + 39; OR: 1.85e + 12, 95% CI: 29.2, 1.18e + 39; and OR: 1.44e + 12, 95% CI: 16.9, 8.70e + 38, respectively). There was no association between PEEP levels and other secondary outcomes.Conclusion: We identified higher PEEP was associated with significantly higher PFR and higher incidence of pneumothorax. Nonetheless, in terms of other outcomes, no significant differences were detected among four levels of PEEP.Systematic Review Registration: The study had registered on an international prospective register of systematic reviews, PROSPERO, on 09 April 2021, identifier: [CRD42021241745].

scholarly journals Association of different positive end-expiratory pressure selection strategies with all-cause mortality in adult patients with acute respiratory distress syndrome

2021 ◽  
Vol 10 (1) ◽  
Author(s):  
Manuel Tisminetzky ◽  
Jose Dianti ◽  
Bruno L. Ferreyro ◽  
Federico Angriman ◽  
Lorenzo Del Sorbo ◽  
...  
Keyword(s):  
Acute Respiratory Distress Syndrome ◽  
Distress Syndrome ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Adult Patients ◽  
Controlled Trials ◽  
Positive End Expiratory Pressure ◽  
Randomized Controlled ◽  
Selection Strategies ◽  
All Cause Mortality

Abstract Background The acute respiratory distress syndrome (ARDS) has high morbidity and mortality. Positive end-expiratory pressure (PEEP) is commonly used in patients with ARDS but the best method to select the optimal PEEP level and reduce all-cause mortality is unclear. The primary objective of this network meta-analysis is to summarize the available evidence and to compare the effect of different PEEP selection strategies on all-cause mortality in adult patients with ARDS. Methods We will search MEDLINE, Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and LILACS from inception onwards for randomized controlled trials assessing the effect of PEEP selection strategies in adult patients with moderate to severe ARDS. We will exclude studies that did not use a lung-protective ventilation approach as part of the comparator or intervention strategy. The primary outcome will be all-cause mortality (at the longest available follow-up and up to 90 days). Secondary outcomes will include barotrauma, ventilator-free days, intensive care unit and hospital length of stay, and changes in oxygenation. Two reviewers will independently screen all citations, full-text articles, and extract study-data. We will assess the risk of bias for each of the outcomes using version 2 of the Cochrane risk of bias tool for randomized controlled trials. If feasible, Bayesian network meta-analyses will be conducted to obtain pooled estimates of all potential head-to-head comparisons. We will report pairwise and network meta-analysis treatment effect estimates as risk ratios and risk differences, together with the associated 95% credible intervals. We will assess certainty in effect estimates using GRADE methodology. Discussion The present study will inform clinical decision-making for adult patients with ARDS and will improve our understanding of the limitations of the available literature assessing PEEP selection strategies. Finally, this information may also inform the design of future randomized trials, including the selection of interventions, comparators, and predictive enrichment strategies. Trial registration PROSPERO 2020 CRD42020193302.

scholarly journals Effects of early extubation followed by noninvasive ventilation versus standard extubation on the duration of invasive mechanical ventilation in hypoxemic non-hypercapnic patients: a systematic review and individual patient data meta-analysis of randomized controlled trials

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Rosanna Vaschetto ◽  
Alessandro Pecere ◽  
Gavin D. Perkins ◽  
Dipesh Mistry ◽  
Gianmaria Cammarota ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Randomized Controlled Trials ◽  
Noninvasive Ventilation ◽  
Individual Patient Data ◽  
Meta Analysis ◽  
Invasive Mechanical Ventilation ◽  
Patient Data ◽  
Controlled Trials ◽  
Early Extubation ◽  
Randomized Controlled

Abstract Background Usefulness of noninvasive ventilation (NIV) in weaning patients with non-hypercapnic hypoxemic acute respiratory failure (hARF) is unclear. The study aims to assess in patients with non-hypercapnic hARF, the efficacy of NIV after early extubation, compared to standard weaning. Methods In this individual patient data meta-analysis, we searched EMBASE, Medline and Cochrane Central Register of Controlled Trials to identify potentially eligible randomized controlled trials published from database inception to October 2020. To be eligible, studies had to include patients treated with NIV after early extubation and compared to conventional weaning in adult non-hypercapnic hARF patients. Anonymized individual patient data from eligible studies were provided by study investigators. Using one-step and two-step meta-analysis models we tested the difference in total days spent on invasive ventilation. Results We screened 1605 records. Six studies were included in quantitative synthesis. Overall, 459 participants (mean [SD] age, 62 [15] years; 269 [59%] males) recovering from hARF were included in the analysis (233 in the intervention group and 226 controls). Participants receiving NIV had a shorter duration of invasive mechanical ventilation compared to control group (mean difference, − 3.43; 95% CI − 5.17 to − 1.69 days, p < 0.001), a shorter duration of total days spent on mechanical ventilation (mean difference, − 2.04; 95% CI − 3.82 to − 0.27 days, p = 0.024), a reduced risk of ventilatory associated pneumonia (odds ratio, 0.24; 95% CI 0.08 to 0.71, p = 0.014), a reduction of time spent in ICU (time ratio, 0.81; 95% CI 0.68 to 0.96, p = 0.015) and in-hospital (time ratio, 0.81; 95% CI 0.69 to 0.95, p = 0.010), with no difference in ICU mortality. Conclusions Although primary studies are limited, using an individual patient data metanalysis approach, NIV after early extubation appears useful in reducing total days spent on invasive mechanical ventilation. Trial registration The protocol was registered to PROSPERO database on 12/06/2019 and available at PROSPERO website inserting the study code i.e., CRD42019133837.

scholarly journals Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) versus low PEEP on patients with moderate–severe acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials

2019 ◽  
Vol 13 ◽  
pp. 175346661985822 ◽  
Author(s):  
Xi Zheng ◽  
Yijia Jiang ◽  
Huimiao Jia ◽  
Wenliang Ma ◽  
Yue Han ◽  
...  
Keyword(s):  
Acute Respiratory Distress Syndrome ◽  
Length Of Stay ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Randomized Controlled Trials ◽  
Distress Syndrome ◽  
Controlled Trials ◽  
Positive End Expiratory Pressure ◽  
Icu Mortality ◽  
Randomized Controlled

Background: Setting a positive end-expiratory pressure (PEEP) on patients with acute respiratory distress syndrome (ARDS) receiving mechanical ventilation has been an issue of great contention. Therefore, we aimed to determine effects of lung recruitment maneuver (RM) and titrated PEEP versus low PEEP on adult patients with moderate–severe ARDS. Methods: Data sources and study selection proceeded as follows: PubMed, Ovid, EBSCO, and Cochrane Library databases were searched from 2003 to May 2018. Original clinical randomized controlled trials which met the eligibility criteria were included. To compare the prognosis between the titrated PEEP and low PEEP groups on patients with moderate–severe ARDS (PaO2/FiO2 < 200 mmHg). Heterogeneity was quantified through the I2 statistic. Egger’s test and funnel plots were used to assess publication bias. Results: No difference was found in 28-day mortality and ICU mortality (OR = 0.97, 95% CI (0.61–1.52), p = 0.88; OR = 1.14, 95% CI (0.91–1.43), p = 0.26, respectively). Only ventilator-free days, length of stay in the ICU, length of stay in hospital, and incidence of barotrauma could be systematically reviewed owing to bias and extensive heterogeneity. Conclusion: No difference was observed in the RM between the titrated PEEP and the low PEEP in 28-day mortality and ICU mortality on patients with moderate–severe ARDS.

Noninvasive Oxygenation Strategies in Immunocompromised Patients With Acute Hypoxemic Respiratory Failure: A Pairwise and Network Meta-Analysis of Randomized Controlled Trials

2019 ◽  
Vol 35 (11) ◽  
pp. 1216-1225 ◽  
Author(s):  
Yazan Zayed ◽  
Momen Banifadel ◽  
Mahmoud Barbarawi ◽  
Babikir Kheiri ◽  
Adam Chahine ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Oxygen Therapy ◽  
Meta Analysis ◽  
Invasive Mechanical Ventilation ◽  
Controlled Trials ◽  
Immunocompromised Patients ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure ◽  
Randomized Controlled

Introduction: Acute hypoxemic respiratory failure (AHRF) is a leading cause of intensive care unit (ICU) admission among immunocompromised patients. Invasive mechanical ventilation is associated with increased morbidity and mortality. Objective: To evaluate the efficacy of various oxygenation strategies including noninvasive ventilation (NIV), high-flow nasal cannula (HFNC), and conventional oxygen therapy in immunocompromised patients with AHRF. Methods: Electronic databases including PubMed, Embase, and the Cochrane Library were reviewed from inception to December 2018. We included all randomized controlled trials (RCTs) comparing different modalities of initial oxygenation strategies in immunocompromised patients with AHRF. Our primary outcome was the need for intubation and invasive mechanical ventilation while secondary outcomes were ICU acquired infections and short- and long-term mortality. Data were extracted separately and independently by 2 reviewers. We performed a Bayesian network meta-analysis to calculate odds ratio (OR) and Bayesian 95% credible intervals (CrIs). Results: Nine RCTs were included (1570 patients, mean age 61.1 ± 13.8 years with 64% male). Noninvasive ventilation was associated with a significantly reduced intubation rate compared with standard oxygen therapy (OR: 0.53; 95% CrI: 0.26-0.91). There were no significant reductions of intubation between NIV versus HFNC (OR: 0.83; 95% CrI: 0.35-2.11) or HFNC versus standard oxygen therapy (OR: 0.65; 95% CrI: 0.26-1.24). There were no significant differences between all groups regarding short-term (28-day or ICU) mortality or long-term (90-day or hospital) mortality or ICU-acquired infections ( P > 0.05). Conclusion: Among immunocompromised patients with AHRF, NIV was associated with a significant reduction of intubation compared with standard oxygen therapy. There were no significant differences among all oxygenation strategies regarding mortality and ICU-acquired infections.

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