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

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.

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

10.21203/rs.3.rs-125434/v1 ◽

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.

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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

Frontiers in Medicine ◽

10.3389/fmed.2021.730018 ◽

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].

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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

Therapeutic Advances in Respiratory Disease ◽

10.1177/1753466619858228 ◽

2019 ◽

Vol 13 ◽

pp. 175346661985822 ◽

Cited By ~ 1

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.

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Role of Neuromuscular Blocking Agents in Acute Respiratory Distress Syndrome: An Updated Meta-Analysis of Randomized Controlled Trials

Frontiers in Pharmacology ◽

10.3389/fphar.2019.01637 ◽

2020 ◽

Vol 10 ◽

Cited By ~ 1

Author(s):

Xue-biao Wei ◽

Zhong-hua Wang ◽

Xiao-long Liao ◽

Wei-xin Guo ◽

Tie-he Qin ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Meta Analysis ◽

Neuromuscular Blocking ◽

Neuromuscular Blocking Agents ◽

Controlled Trials ◽

Randomized Controlled

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Effect of surfactant administration on outcomes of adult patients in acute respiratory distress syndrome: a meta-analysis of randomized controlled trials

BMC Pulmonary Medicine ◽

10.1186/s12890-018-0761-y ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 7

Author(s):

Shan-Shan Meng ◽

Wei Chang ◽

Zhong-Hua Lu ◽

Jian-Feng Xie ◽

Hai-Bo Qiu ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Randomized Controlled Trials ◽

Distress Syndrome ◽

Meta Analysis ◽

Adult Patients ◽

Controlled Trials ◽

Randomized Controlled ◽

Surfactant Administration

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Is high-frequency oscillatory ventilation more effective and safer than conventional protective ventilation in adult acute respiratory distress syndrome patients? A meta-analysis of randomized controlled trials

Critical Care ◽

10.1186/cc13900 ◽

2014 ◽

Vol 18 (3) ◽

pp. R111 ◽

Cited By ~ 25

Author(s):

Xiao-ling Gu ◽

Guan-nan Wu ◽

Yan-wen Yao ◽

Dong-hong Shi ◽

Yong Song

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

High Frequency ◽

Distress Syndrome ◽

Meta Analysis ◽

High Frequency Oscillatory Ventilation ◽

Protective Ventilation ◽

Controlled Trials ◽

Randomized Controlled ◽

High Frequency Oscillatory

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Effects of Cytokine Blocking Agents on 30-Day Mortality in Patients Admitted to ICU With Acute Respiratory Distress Syndrome by SARS-CoV2 Infection: An Observational Cohort Study

10.21203/rs.3.rs-37561/v1 ◽

2020 ◽

Author(s):

Irene Coloretti ◽

Stefano Busani ◽

Emanuela Biagioni ◽

Sophie Venturelli ◽

Elena Munari ◽

...

Keyword(s):

Mechanical Ventilation ◽

Acute Respiratory Distress Syndrome ◽

Cohort Study ◽

Hospital Mortality ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Cox Model ◽

Invasive Mechanical Ventilation ◽

Blocking Agents

Abstract Background The use of cytokine-blocking agents has been proposed to modulate the inflammatory response in patients with COVID19. Tocilizumab and Anakinra were included in the local protocol as an optional treatment in critically ill patients with acute respiratory distress syndrome (ARDS) by SARS-CoV2 infection. This cohort study evaluated the effects of therapy with cytokine blocking agents on in-hospital mortality in COVID19 patients requiring mechanical ventilation and admitted to intensive care unit. Methods The association between therapy with Tocilizumab or Anakinra and in-hospital mortality was assessed in consecutive adult COVID19 patients admitted to our ICU with moderate to severe ARDS. The association was evaluated by comparing patients who receive to those who did not receive Tocilizumab or Anakinra and by using different multivariable Cox models adjusted for variables related to poor outcome, for the propensity to be treated with Tocilizumab or Anakinra and after patient matching. Results Sixty-six patients who received immunotherapy (49 Tocilizumab, 17 Anakinra) and 28 patients who did not receive immunotherapy were included. The in-hospital crude mortality was 30,3% in treated patients and 50% in non-treated (OR 0,77, 95% CI 0,56-1,05, p=0,069). The adjusted Cox model showed an association between therapy with immunotherapy and in-hospital mortality (HR 0,35, 95% CI 0,16-0,77, p=0,009). This protective effect was further confirmed in the analysis adjusted for propensity score, in the propensity-matched cohort and in the cohort of patients with invasive mechanical ventilation within 2 hours after ICU admission. Conclusions Although important limitations, our study showed that cytokine-blocking agents seem to be safe and to improve survival in COVID-19 patients admitted to ICU with ARDS and the need of mechanical ventilation.

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Effects of Cytokine Blocking Agents on Hospital Mortality in Patients Admitted to ICU With Acute Respiratory Distress Syndrome by SARS-CoV2 Infection: An Observational Cohort Study

10.21203/rs.3.rs-37561/v2 ◽

2020 ◽

Author(s):

Irene Coloretti ◽

Stefano Busani ◽

Emanuela Biagioni ◽

Sophie Venturelli ◽

Elena Munari ◽

...

Keyword(s):

Mechanical Ventilation ◽

Acute Respiratory Distress Syndrome ◽

Cohort Study ◽

Hospital Mortality ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Cox Model ◽

Invasive Mechanical Ventilation ◽

Blocking Agents

Abstract Background The use of cytokine-blocking agents has been proposed to modulate the inflammatory response in patients with COVID19. Tocilizumab and Anakinra were included in the local protocol as an optional treatment in critically ill patients with acute respiratory distress syndrome (ARDS) by SARS-CoV2 infection. This cohort study evaluated the effects of therapy with cytokine blocking agents on in-hospital mortality in COVID19 patients requiring mechanical ventilation and admitted to intensive care unit. Methods The association between therapy with Tocilizumab or Anakinra and in-hospital mortality was assessed in consecutive adult COVID19 patients admitted to our ICU with moderate to severe ARDS. The association was evaluated by comparing patients who receive to those who did not receive Tocilizumab or Anakinra and by using different multivariable Cox models adjusted for variables related to poor outcome, for the propensity to be treated with Tocilizumab or Anakinra and after patient matching. Results Sixty-six patients who received immunotherapy (49 Tocilizumab, 17 Anakinra) and 28 patients who did not receive immunotherapy were included. The in-hospital crude mortality was 30,3% in treated patients and 50% in non-treated (OR 0,77, 95% CI 0,56-1,05, p=0,069). The adjusted Cox model showed an association between therapy with immunotherapy and in-hospital mortality (HR 0,35, 95% CI 0,16-0,77, p=0,009). This protective effect was further confirmed in the analysis adjusted for propensity score, in the propensity-matched cohort and in the cohort of patients with invasive mechanical ventilation within 2 hours after ICU admission. Conclusions Although important limitations, our study showed that cytokine-blocking agents seem to be safe and to improve survival in COVID-19 patients admitted to ICU with ARDS and the need of mechanical ventilation.

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