In conclusion, this prospective international prevalence study found that PP was used in 32.9% of patients with severe ARDS, and was associated with low complication rates, significant increase in oxygenation and a significant decrease in driving pressure.

BackgroundPatients liberated from invasive mechanical ventilation are at risk of extubation failure, including inability to breathe without a tracheal tube (airway failure) or without mechanical ventilation (non-airway failure). We sought to identify respective risk factors for airway failure and non-airway failure following extubation.MethodsThe primary endpoint of this prospective, observational, multicenter study in 26 intensive care units was extubation failure, defined as need for reintubation within 48 h following extubation. A multinomial logistic regression model was used to identify risk factors for airway failure and non-airway failure.ResultsBetween 1 December 2013 and 1 May 2015, 1514 patients undergoing extubation were enrolled. The extubation-failure rate was 10.4% (157/1514), including 70/157 (45%) airway failures, 78/157 (50%) non-airway failures, and 9/157 (5%) mixed airway and non-airway failures. By multivariable analysis, risk factors for extubation failure were either common to airway failure and non-airway failure: intubation for coma (OR 4.979 (2.797–8.864), P < 0.0001 and OR 2.067 (1.217–3.510), P = 0.003, respectively, intubation for acute respiratory failure (OR 3.395 (1.877–6.138), P < 0.0001 and OR 2.067 (1.217–3.510), P = 0.007, respectively, absence of strong cough (OR 1.876 (1.047–3.362), P = 0.03 and OR 3.240 (1.786–5.879), P = 0.0001, respectively, or specific to each specific mechanism: female gender (OR 2.024 (1.187–3.450), P = 0.01), length of ventilation > 8 days (OR 1.956 (1.087–3.518), P = 0.025), copious secretions (OR 4.066 (2.268–7.292), P < 0.0001) were specific to airway failure, whereas non-obese status (OR 2.153 (1.052–4.408), P = 0.036) and sequential organ failure assessment (SOFA) score ≥ 8 (OR 1.848 (1.100–3.105), P = 0.02) were specific to non-airway failure. Both airway failure and non-airway failure were associated with ICU mortality (20% and 22%, respectively, as compared to 6% in patients with extubation success, P < 0.0001).ConclusionsSpecific risk factors have been identified, allowing us to distinguish between risk of airway failure and non-airway failure. The two conditions will be managed differently, both for prevention and curative strategies.Trial registrationClinicalTrials.gov, NCT 02450669. Registered on 21 May 2015. Electronic supplementary materialThe online version of this article (10.1186/s13054-018-2150-6) contains supplementary material, which is available to authorized users.

Purpose: Among acute respiratory distress syndrome (ARDS) patients in intensive care units, the efficacy of lung recruitment maneuver (LRM) use is uncertain taking into account the most recent randomized controlled trials (RCTs). We aimed to estimate the effect of LRMs on mortality from ARDS. Methods: In this systematic review and meta-analysis, we searched for RCTs comparing mechanical ventilation with and without LRMs in adults with ARDS. We generated pooled relative risks (RR), mean difference, performed trialsequential-analysis and cumulative meta-analysis. The primary outcome was 28-day mortality. The secondary outcomes were oxygenation evaluated by PaO 2 /FiO 2 ratio, rate of rescue therapy and rate of hemodynamic compromise. Results: In 14 RCTs including 3185 patients, LRMs were not associated with reduced 28-day mortality (RR = 0.92, 95% confidence interval (95% CI) 0.82-1.04, P = 0.21), compared to no-LRM. Trial-sequential-analysis showed that the required information size has been accrued. PaO 2 /FiO 2 ratio was significantly higher in the LRMs group in comparison to the no-LRM group (mean difference = 47.6 mmHg, 95% CI 33.4-61.8, P < 0.001). LRMs were associated with a decreased rate of rescue therapy (RR = 0.69 95% CI 0.56-0.84, P < 0.001), and an increased rate of hemodynamic compromise (RR = 1.19, 95% CI 1.06-1.33, P = 0.002), compared to no-LRM group. Using cumulative meta-analysis, a significant change for effect on mortality was observed after 2017. Conclusions: The results suggest that in ARDS patients, systematic use of LRMs does not significantly improve 28-day mortality. However, LRM use was associated with positive effects such as an oxygenation improvement and a less frequent use of rescue therapy. Nevertheless, LRM use was associated with negative effects such as hemodynamic impairment.