Lorenzo Ball1,2,3, Ary Serpa Neto4,5, Valeria Trifiletti6, Maura Mandelli6, Iacopo Firpo6, Chiara Robba7, Marcelo Gama de Abreu8, Marcus J Schultz4,9,10, Nicolò Patroniti6,7, Patricia R M Rocco11, Paolo Pelosi6,7. 1. Department of Surgical Sciences and Integrated Diagnostics, University of Genova, Largo Rosanna Benzi 8, 16131, Genova, Italy. lorenzo.ball@edu.unige.it. 2. Anesthesia and Intensive Care, Ospedale Policlinico San Martino IRCCS per l'Oncologia e le Neuroscienze, Genova, Italy. lorenzo.ball@edu.unige.it. 3. Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands. lorenzo.ball@edu.unige.it. 4. Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands. 5. Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil. 6. Department of Surgical Sciences and Integrated Diagnostics, University of Genova, Largo Rosanna Benzi 8, 16131, Genova, Italy. 7. Anesthesia and Intensive Care, Ospedale Policlinico San Martino IRCCS per l'Oncologia e le Neuroscienze, Genova, Italy. 8. Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany. 9. Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand. 10. Nuffield Department of Medicine, University of Oxford, Oxford, UK. 11. Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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 .
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 .
Authors: L Ball; S N T Hemmes; A Serpa Neto; T Bluth; J Canet; M Hiesmayr; M W Hollmann; G H Mills; M F Vidal Melo; C Putensen; W Schmid; P Severgnini; H Wrigge; M Gama de Abreu; M J Schultz; P Pelosi Journal: Br J Anaesth Date: 2018-06-02 Impact factor: 9.166
Authors: Carol Hodgson; Ewan C Goligher; Meredith E Young; Jennifer L Keating; Anne E Holland; Lorena Romero; Scott J Bradley; David Tuxen Journal: Cochrane Database Syst Rev Date: 2016-11-17
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Authors: Lorenzo Ball; Denise Battaglini; Chiara Robba; Danilo Cardim; Emanuela Moncalvo; Iole Brunetti; Matteo Bassetti; Daniele R Giacobbe; Antonio Vena; Nicolò Patroniti; Patricia R M Rocco; Basil F Matta; Paolo Pelosi Journal: Crit Care Date: 2021-03-19 Impact factor: 9.097
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Authors: Lorenzo Ball; Pedro Leme Silva; Daniele Roberto Giacobbe; Matteo Bassetti; Gustavo R Zubieta-Calleja; Patricia R M Rocco; Paolo Pelosi Journal: Expert Rev Respir Med Date: 2022-03-30 Impact factor: 4.300
Authors: Paolo Pelosi; Lorenzo Ball; Carmen S V Barbas; Rinaldo Bellomo; Karen E A Burns; Sharon Einav; Luciano Gattinoni; John G Laffey; John J Marini; Sheila N Myatra; Marcus J Schultz; Jean Louis Teboul; Patricia R M Rocco Journal: Crit Care Date: 2021-07-16 Impact factor: 9.097