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- Title
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.
- Authors
Ball, Lorenzo; Serpa Neto, Ary; Trifiletti, Valeria; Mandelli, Maura; Firpo, Iacopo; Robba, Chiara; Gama de Abreu, Marcelo; Schultz, Marcus J.; Patroniti, Nicolò; Rocco, Patricia R. M.; Pelosi, Paolo
- 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 (VT) 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 VT, the routine use of higher PEEP and/or RMs did not reduce mortality in unselected patients with ARDS. Trial registration: PROSPERO CRD42017082035.
- Subjects
POSITIVE end-expiratory pressure; SEQUENTIAL analysis; MORTALITY; RANDOMIZED controlled trials; ADULT respiratory distress syndrome
- Publication
Intensive Care Medicine Experimental, 2020, Vol 8, p1
- ISSN
2197-425X
- Publication type
Article
- DOI
10.1186/s40635-020-00322-2