Lung recruitment maneuvers for adult patients with acute respiratory distress syndrome: A systematic review and meta-analysis

Ewan C. Goligher, Carol L. Hodgson, Neill K.J. Adhikari, Maureen O. Meade, Hannah Wunsch, Elizabeth Uleryk, Ognjen Gajic, Marcelo P.B. Amato, Niall D. Ferguson, Gordon D. Rubenfeld, Eddy Fan

Research output: Contribution to journalReview article

14 Citations (Scopus)

Abstract

Rationale: In patients with acute respiratory distress syndrome (ARDS), lung recruitment maneuvers (LRMs) may prevent ventilator-induced lung injury and improve survival. Objectives: To summarize the current evidence in support of the use of LRMs in adult patients with ARDS and to inform the recently published American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline on mechanical ventilation in ARDS. Methods: We conducted a systematic review and meta-analysis of randomized trials comparing mechanical ventilation strategies with and without LRMs. Eligible trials were identified from among previously published systematic reviews and an updated literature search. Data on 28-day mortality, oxygenation, adverse events, and use of rescue therapy were collected, and results were pooled using random effects models weighted by inverse variance. Strength of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Results: We screened 430 citations and previous systematic reviews and found six trials eligible for inclusion (n = 1,423 patients in total). The type of LRM varied widely between trials, and five of the trials involved a cointervention with a higher positive end-expiratory pressure (PEEP) ventilation strategy. Risk of bias was deemed high in one trial. In the primary analysis, the only trial without a cointervention showed that LRMs were associated with reduced mortality (one trial; risk ratio [RR], 0.62; 95% confidence interval [CI], 0.39–0.98; evidence grade = low). Meta-analysis of all six trials also suggested a significant mortality reduction (six trials; RR, 0.81; 95% CI, 0.69–0.95; evidence grade = moderate), and the use of a higher PEEP cointervention did not significantly modify the mortality effect (P = 0.27 for heterogeneity). LRMs were also associated with improved oxygenation after 24 hours (six trials; mean increase, 52 mm Hg; 95% CI, 23–81 mm Hg) and less frequent requirement for rescue therapy (three trials; RR, 0.65; 95% CI, 0.45–0.94). LRMs were not associated with an increased rate of barotrauma (four trials; RR, 0.84; 95% CI, 0.46–1.55). The rate of hemodynamic compromise was not significantly increased with LRMs (three trials; RR, 1.30; 95% CI, 0.92–1.78). Conclusions: Randomized trials suggest that LRMs in combination with a higher PEEP ventilation strategy reduce mortality, but confidence in this finding is limited. Further trials are required to confirm benefit from LRMs in adults with ARDS.

Original languageEnglish (US)
Pages (from-to)S304-S311
JournalAnnals of the American Thoracic Society
Volume14
DOIs
StatePublished - Oct 1 2017

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Adult Respiratory Distress Syndrome
Meta-Analysis
Lung
Confidence Intervals
Odds Ratio
Positive-Pressure Respiration
Mortality
Artificial Respiration
Ventilator-Induced Lung Injury
Barotrauma
Practice Guidelines
Hemodynamics
Survival

Keywords

  • Acute respiratory distress syndrome
  • Artificial
  • Lung recruitment
  • Positive end-expiratory pressure
  • Respiration

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine

Cite this

Lung recruitment maneuvers for adult patients with acute respiratory distress syndrome : A systematic review and meta-analysis. / Goligher, Ewan C.; Hodgson, Carol L.; Adhikari, Neill K.J.; Meade, Maureen O.; Wunsch, Hannah; Uleryk, Elizabeth; Gajic, Ognjen; Amato, Marcelo P.B.; Ferguson, Niall D.; Rubenfeld, Gordon D.; Fan, Eddy.

In: Annals of the American Thoracic Society, Vol. 14, 01.10.2017, p. S304-S311.

Research output: Contribution to journalReview article

Goligher, EC, Hodgson, CL, Adhikari, NKJ, Meade, MO, Wunsch, H, Uleryk, E, Gajic, O, Amato, MPB, Ferguson, ND, Rubenfeld, GD & Fan, E 2017, 'Lung recruitment maneuvers for adult patients with acute respiratory distress syndrome: A systematic review and meta-analysis', Annals of the American Thoracic Society, vol. 14, pp. S304-S311. https://doi.org/10.1513/AnnalsATS.201704-340OT
Goligher, Ewan C. ; Hodgson, Carol L. ; Adhikari, Neill K.J. ; Meade, Maureen O. ; Wunsch, Hannah ; Uleryk, Elizabeth ; Gajic, Ognjen ; Amato, Marcelo P.B. ; Ferguson, Niall D. ; Rubenfeld, Gordon D. ; Fan, Eddy. / Lung recruitment maneuvers for adult patients with acute respiratory distress syndrome : A systematic review and meta-analysis. In: Annals of the American Thoracic Society. 2017 ; Vol. 14. pp. S304-S311.
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abstract = "Rationale: In patients with acute respiratory distress syndrome (ARDS), lung recruitment maneuvers (LRMs) may prevent ventilator-induced lung injury and improve survival. Objectives: To summarize the current evidence in support of the use of LRMs in adult patients with ARDS and to inform the recently published American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline on mechanical ventilation in ARDS. Methods: We conducted a systematic review and meta-analysis of randomized trials comparing mechanical ventilation strategies with and without LRMs. Eligible trials were identified from among previously published systematic reviews and an updated literature search. Data on 28-day mortality, oxygenation, adverse events, and use of rescue therapy were collected, and results were pooled using random effects models weighted by inverse variance. Strength of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Results: We screened 430 citations and previous systematic reviews and found six trials eligible for inclusion (n = 1,423 patients in total). The type of LRM varied widely between trials, and five of the trials involved a cointervention with a higher positive end-expiratory pressure (PEEP) ventilation strategy. Risk of bias was deemed high in one trial. In the primary analysis, the only trial without a cointervention showed that LRMs were associated with reduced mortality (one trial; risk ratio [RR], 0.62; 95{\%} confidence interval [CI], 0.39–0.98; evidence grade = low). Meta-analysis of all six trials also suggested a significant mortality reduction (six trials; RR, 0.81; 95{\%} CI, 0.69–0.95; evidence grade = moderate), and the use of a higher PEEP cointervention did not significantly modify the mortality effect (P = 0.27 for heterogeneity). LRMs were also associated with improved oxygenation after 24 hours (six trials; mean increase, 52 mm Hg; 95{\%} CI, 23–81 mm Hg) and less frequent requirement for rescue therapy (three trials; RR, 0.65; 95{\%} CI, 0.45–0.94). LRMs were not associated with an increased rate of barotrauma (four trials; RR, 0.84; 95{\%} CI, 0.46–1.55). The rate of hemodynamic compromise was not significantly increased with LRMs (three trials; RR, 1.30; 95{\%} CI, 0.92–1.78). Conclusions: Randomized trials suggest that LRMs in combination with a higher PEEP ventilation strategy reduce mortality, but confidence in this finding is limited. Further trials are required to confirm benefit from LRMs in adults with ARDS.",
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author = "Goligher, {Ewan C.} and Hodgson, {Carol L.} and Adhikari, {Neill K.J.} and Meade, {Maureen O.} and Hannah Wunsch and Elizabeth Uleryk and Ognjen Gajic and Amato, {Marcelo P.B.} and Ferguson, {Niall D.} and Rubenfeld, {Gordon D.} and Eddy Fan",
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T1 - Lung recruitment maneuvers for adult patients with acute respiratory distress syndrome

T2 - A systematic review and meta-analysis

AU - Goligher, Ewan C.

AU - Hodgson, Carol L.

AU - Adhikari, Neill K.J.

AU - Meade, Maureen O.

AU - Wunsch, Hannah

AU - Uleryk, Elizabeth

AU - Gajic, Ognjen

AU - Amato, Marcelo P.B.

AU - Ferguson, Niall D.

AU - Rubenfeld, Gordon D.

AU - Fan, Eddy

PY - 2017/10/1

Y1 - 2017/10/1

N2 - Rationale: In patients with acute respiratory distress syndrome (ARDS), lung recruitment maneuvers (LRMs) may prevent ventilator-induced lung injury and improve survival. Objectives: To summarize the current evidence in support of the use of LRMs in adult patients with ARDS and to inform the recently published American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline on mechanical ventilation in ARDS. Methods: We conducted a systematic review and meta-analysis of randomized trials comparing mechanical ventilation strategies with and without LRMs. Eligible trials were identified from among previously published systematic reviews and an updated literature search. Data on 28-day mortality, oxygenation, adverse events, and use of rescue therapy were collected, and results were pooled using random effects models weighted by inverse variance. Strength of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Results: We screened 430 citations and previous systematic reviews and found six trials eligible for inclusion (n = 1,423 patients in total). The type of LRM varied widely between trials, and five of the trials involved a cointervention with a higher positive end-expiratory pressure (PEEP) ventilation strategy. Risk of bias was deemed high in one trial. In the primary analysis, the only trial without a cointervention showed that LRMs were associated with reduced mortality (one trial; risk ratio [RR], 0.62; 95% confidence interval [CI], 0.39–0.98; evidence grade = low). Meta-analysis of all six trials also suggested a significant mortality reduction (six trials; RR, 0.81; 95% CI, 0.69–0.95; evidence grade = moderate), and the use of a higher PEEP cointervention did not significantly modify the mortality effect (P = 0.27 for heterogeneity). LRMs were also associated with improved oxygenation after 24 hours (six trials; mean increase, 52 mm Hg; 95% CI, 23–81 mm Hg) and less frequent requirement for rescue therapy (three trials; RR, 0.65; 95% CI, 0.45–0.94). LRMs were not associated with an increased rate of barotrauma (four trials; RR, 0.84; 95% CI, 0.46–1.55). The rate of hemodynamic compromise was not significantly increased with LRMs (three trials; RR, 1.30; 95% CI, 0.92–1.78). Conclusions: Randomized trials suggest that LRMs in combination with a higher PEEP ventilation strategy reduce mortality, but confidence in this finding is limited. Further trials are required to confirm benefit from LRMs in adults with ARDS.

AB - Rationale: In patients with acute respiratory distress syndrome (ARDS), lung recruitment maneuvers (LRMs) may prevent ventilator-induced lung injury and improve survival. Objectives: To summarize the current evidence in support of the use of LRMs in adult patients with ARDS and to inform the recently published American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline on mechanical ventilation in ARDS. Methods: We conducted a systematic review and meta-analysis of randomized trials comparing mechanical ventilation strategies with and without LRMs. Eligible trials were identified from among previously published systematic reviews and an updated literature search. Data on 28-day mortality, oxygenation, adverse events, and use of rescue therapy were collected, and results were pooled using random effects models weighted by inverse variance. Strength of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Results: We screened 430 citations and previous systematic reviews and found six trials eligible for inclusion (n = 1,423 patients in total). The type of LRM varied widely between trials, and five of the trials involved a cointervention with a higher positive end-expiratory pressure (PEEP) ventilation strategy. Risk of bias was deemed high in one trial. In the primary analysis, the only trial without a cointervention showed that LRMs were associated with reduced mortality (one trial; risk ratio [RR], 0.62; 95% confidence interval [CI], 0.39–0.98; evidence grade = low). Meta-analysis of all six trials also suggested a significant mortality reduction (six trials; RR, 0.81; 95% CI, 0.69–0.95; evidence grade = moderate), and the use of a higher PEEP cointervention did not significantly modify the mortality effect (P = 0.27 for heterogeneity). LRMs were also associated with improved oxygenation after 24 hours (six trials; mean increase, 52 mm Hg; 95% CI, 23–81 mm Hg) and less frequent requirement for rescue therapy (three trials; RR, 0.65; 95% CI, 0.45–0.94). LRMs were not associated with an increased rate of barotrauma (four trials; RR, 0.84; 95% CI, 0.46–1.55). The rate of hemodynamic compromise was not significantly increased with LRMs (three trials; RR, 1.30; 95% CI, 0.92–1.78). Conclusions: Randomized trials suggest that LRMs in combination with a higher PEEP ventilation strategy reduce mortality, but confidence in this finding is limited. Further trials are required to confirm benefit from LRMs in adults with ARDS.

KW - Acute respiratory distress syndrome

KW - Artificial

KW - Lung recruitment

KW - Positive end-expiratory pressure

KW - Respiration

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