Intensive Care Medicine Experimental (Dec 2020)

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

  • Lorenzo Ball,
  • Ary Serpa Neto,
  • Valeria Trifiletti,
  • Maura Mandelli,
  • Iacopo Firpo,
  • Chiara Robba,
  • Marcelo Gama de Abreu,
  • Marcus J. Schultz,
  • Nicolò Patroniti,
  • Patricia R. M. Rocco,
  • Paolo Pelosi,
  • For the PROVE Network: PROtective Ventilation Network

DOI
https://doi.org/10.1186/s40635-020-00322-2
Journal volume & issue
Vol. 8, no. S1
pp. 1 – 16

Abstract

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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 .

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