Sachin Sud1,2, Jan O Friedrich3, Neill K J Adhikari3,4,5, Eddy Fan3,4, Niall D Ferguson3,4, Gordon Guyatt6, Maureen O Meade7. 1. Division of Critical Care, Department of Medicine, Trillium Health Partners-University of Toronto, Mississauga, Ontario, Canada. 2. Institute of Better Health, Trillium Health Partners, Mississauga, Ontario, Canada. 3. Interdepartmental Division of Critical Care Medicine. 4. Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. 5. Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. 6. Department of Health Research Methods, Evidence and Impact. 7. Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Abstract
Rationale: Choosing the best ventilation strategy for acute respiratory distress syndrome (ARDS) is complex, yet it is highly relevant to clinicians during a respiratory pandemic. Objectives: To compare the effects of low Vt, high Vt, high positive end-expiratory pressure (PEEP), prone ventilation, high-frequency oscillation, and venovenous extracorporeal membrane oxygenation (VV ECMO) on mortality in ARDS. Methods: We performed a network meta-analysis of randomized trials. We applied the Grading of Recommendations Assessment, Development and Evaluation methodology to discern the relative effect of interventions on mortality. Measurements and Main Results: We analyzed 34 trials including 9,085 adults with primarily moderate-to-severe ARDS (median baseline PaO2/FiO2, 118; interquartile range, 110-143). Prone positioning combined with low Vt was the best strategy (risk ratio [RR], 0.74 [95% confidence interval (CI), 0.60-0.92] vs. low Vt; high certainty). VV ECMO was also rated among the best (RR, 0.78 [95% CI, 0.58-1.05] vs. low Vt; RR, 0.66; [95% CI, 0.49-0.88] vs. high Vt) but was rated with lower certainty because VV ECMO was restricted to very severe ARDS (mean baseline PaO2/FiO2<75). High PEEP combined with low Vt was rated intermediately (RR, 0.91 [95% CI, 0.81-1.03] vs. low Vt; low certainty; RR, 0.77 [95% CI, 0.65-0.91] vs. high Vt; moderate certainty). High Vt was rated worst (RR, 1.19 [95% CI, 1.02-1.37] vs. low Vt; moderate certainty), and we found no support for high-frequency oscillation or high Vt with prone ventilation. Conclusions: These findings suggest that combining low Vt with prone ventilation is associated with the greatest reduction in mortality for critically ill adults with moderate-to-severe ARDS.
Rationale: Choosing the best ventilation strategy for acute respiratory distress syndrome (ARDS) is complex, yet it is highly relevant to clinicians during a respiratory pandemic. Objectives: To compare the effects of low Vt, high Vt, high positive end-expiratory pressure (PEEP), prone ventilation, high-frequency oscillation, and venovenous extracorporeal membrane oxygenation (VV ECMO) on mortality in ARDS. Methods: We performed a network meta-analysis of randomized trials. We applied the Grading of Recommendations Assessment, Development and Evaluation methodology to discern the relative effect of interventions on mortality. Measurements and Main Results: We analyzed 34 trials including 9,085 adults with primarily moderate-to-severe ARDS (median baseline PaO2/FiO2, 118; interquartile range, 110-143). Prone positioning combined with low Vt was the best strategy (risk ratio [RR], 0.74 [95% confidence interval (CI), 0.60-0.92] vs. low Vt; high certainty). VV ECMO was also rated among the best (RR, 0.78 [95% CI, 0.58-1.05] vs. low Vt; RR, 0.66; [95% CI, 0.49-0.88] vs. high Vt) but was rated with lower certainty because VV ECMO was restricted to very severe ARDS (mean baseline PaO2/FiO2<75). High PEEP combined with low Vt was rated intermediately (RR, 0.91 [95% CI, 0.81-1.03] vs. low Vt; low certainty; RR, 0.77 [95% CI, 0.65-0.91] vs. high Vt; moderate certainty). High Vt was rated worst (RR, 1.19 [95% CI, 1.02-1.37] vs. low Vt; moderate certainty), and we found no support for high-frequency oscillation or high Vt with prone ventilation. Conclusions: These findings suggest that combining low Vt with prone ventilation is associated with the greatest reduction in mortality for critically ill adults with moderate-to-severe ARDS.
Authors: Chad H Hochberg; Kevin J Psoter; Sarina K Sahetya; Eric P Nolley; Shakir Hossen; William Checkley; Meeta P Kerlin; Michelle N Eakin; David N Hager Journal: Crit Care Explor Date: 2022-05-13
Authors: Shelsey W Johnson; Michael A Garcia; Emily K Q Sisson; Christopher R Sheldrick; Vishakha K Kumar; Karen Boman; Scott Bolesta; Vikas Bansal; Amos Lal; J P Domecq; Roman R Melamed; Amy B Christie; Abdurrahman Husain; Santiago Yus; Ognjen Gajic; Rahul Kashyap; Allan J Walkey Journal: Crit Care Explor Date: 2022-02-18
Authors: Michael Cardinale; Salah Boussen; Pierre-Julien Cungi; Pierre Esnault; Quentin Mathais; Julien Bordes; Eric Meaudre; Philippe Goutorbe Journal: Crit Care Med Date: 2022-02-11 Impact factor: 9.296