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

Intensive Care Medicine Experimental

For the PROVE Network: PROtective Ventilation Network¹  Chiara Robba²  Ary Serpa Neto³  Marcus J. Schultz³  Lorenzo Ball⁴  Iacopo Firpo⁴  Valeria Trifiletti⁴  Nicolò Patroniti⁴  Maura Mandelli⁴  Paolo Pelosi⁴  Patricia R. M. Rocco⁵  Marcelo Gama de Abreu⁶ 

[1] ;Anesthesia and Intensive Care, Ospedale Policlinico San Martino IRCCS per l’Oncologia e le Neuroscienze;Department of Intensive Care, Academic Medical Center, University of Amsterdam;Department of Surgical Sciences and Integrated Diagnostics, University of Genova;Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro;Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden;

关键词: Acute respiratory distress syndrome;    Positive end-expiratory pressure;    Mechanical ventilation;   

DOI  :  10.1186/s40635-020-00322-2

来源: DOAJ

【 摘 要 】

Abstract 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 T) 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 T, the routine use of higher PEEP and/or RMs did not reduce mortality in unselected patients with ARDS. Trial registration PROSPERO CRD42017082035 .

【 授权许可】

Unknown