Association of Positive End-Expiratory Pressure and Lung Recruitment Selection Strategies with Mortality in Acute Respiratory Distress Syndrome: A Systematic Review and Network Meta-analysis

Dianti, José; Tisminetzky, Manuel; Ferreyro, Bruno L.; Englesakis, Marina; Sorbo, Lorenzo Del; Sud, Sachin; Talmor, Daniel; Ball, Lorenzo; Meade, Maureen O.; Hodgson, Carol; Beitler, Jeremy R.; Sahetya, Sarina K.; Nichol, Alistair; Fan, Eddy; Rochwerg, Bram; Brochard, Laurent; Slutsky, Arthur S.; Ferguson, Niall D.; Neto, Ary Serpa; Adhikari, Neill K. J.; Angriman, Federico; Goligher, Ewan C.

doi:10.1164/rccm.202108-1972oc

Cited by 48 publications

(32 citation statements)

References 53 publications

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“…60 The key finding of this analysis was that a higher PEEP strategy without a lung recruitment manoeuvre was most likely to be beneficial compared with a lower PEEP strategy (probability of mortality benefit was 99%), whereas a prolonged recruitment manoeuvre with a higher PEEP strategy probably caused harm compared with a higher PEEP strategy without a recruitment maneouvre (probability of increased mortality was 99%). 60 Heterogeneity of individual patient responses to PEEP strategies is recognised, 61 and there is increasing interest in personalised PEEP strategies, although to date these have not shown additional benefit over conventional PEEP strategies. 62,63 Driving pressure (ie, plateau pressure minus end expiratory pressure) might be an independent predictor of survival in patients with ARDS.…”

Section: Ventilation Strategiesmentioning

confidence: 89%

Acute respiratory distress syndrome in adults: diagnosis, outcomes, long-term sequelae, and management

Gorman¹,

O’Kane²,

McAuley³

2022

The Lancet

109

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Section: Ventilation Strategiesmentioning

confidence: 89%

Acute respiratory distress syndrome in adults: diagnosis, outcomes, long-term sequelae, and management

Gorman¹,

O’Kane²,

McAuley³

2022

The Lancet

109

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“…Although higher (compared with lower) levels of PEEP are associated with physiological improvements and clinical benefits in critically ill patients with or without acute respiratory distress syndrome, the impact of obesity in adjusting well tolerated levels of PEEP has not been explored so far. 41,42 Given the worldwide obesity epidemic, further well designed and powered studies are needed to examine the optimal ventilatory strategy in the increasing numbers of obese patients who may require emergency surgery following trauma or sepsis.…”

Section: Discussionmentioning

confidence: 99%

Distribution of ventilation and oxygenation in surgical obese patients ventilated with high versus low positive end-expiratory pressure

Ellenberger

Pelosi

Abreu

et al. 2022

European Journal of Anaesthesiology

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BACKGROUNDIntra-operative ventilation using low/physiological tidal volume and positive end-expiratory pressure (PEEP) with periodic alveolar recruitment manoeuvres (ARMs) is recommended in obese surgery patients.OBJECTIVESTo investigate the effects of PEEP levels and ARMs on ventilation distribution, oxygenation, haemodynamic parameters and cerebral oximetry.DESIGNA substudy of a randomised controlled trial.SETTINGTertiary medical centre in Geneva, Switzerland, between 2015 and 2018.PATIENTSOne hundred and sixty-two patients with a BMI at least 35 kg per square metre undergoing elective open or laparoscopic surgery lasting at least 120 min.INTERVENTIONPatients were randomised to PEEP of 4 cmH2O (n = 79) or PEEP of 12 cmH2O with hourly ARMs (n = 83).MAIN OUTCOME MEASURESThe primary endpoint was the fraction of ventilation in the dependent lung as measured by electrical impedance tomography. Secondary endpoints were the oxygen saturation index (SaO2/FIO2 ratio), respiratory and haemodynamic parameters, and cerebral tissue oximetry.RESULTSCompared with low PEEP, high PEEP was associated with smaller intra-operative decreases in dependent lung ventilation [-11.2%; 95% confidence interval (CI) -8.7 to -13.7 vs. -13.9%; 95% CI -11.7 to -16.5; P = 0.029], oxygen saturation index (-49.6%; 95% CI -48.0 to -51.3 vs. -51.3%; 95% CI -49.6 to -53.1; P < 0.001) and a lower driving pressure (-6.3 cmH2O; 95% CI -5.7 to -7.0). Haemodynamic parameters did not differ between the groups, except at the end of ARMs when arterial pressure and cardiac index decreased on average by -13.7 mmHg (95% CI -12.5 to -14.9) and by -0.54 l min-1 m-2 (95% CI -0.49 to -0.59) along with increased cerebral tissue oximetry (3.0 and 3.2% on left and right front brain, respectively).CONCLUSIONIn obese patients undergoing abdominal surgery, intra-operative PEEP of 12 cmH2O with periodic ARMs, compared with intra-operative PEEP of 4 cmH2O without ARMs, slightly redistributed ventilation to dependent lung zones with minor improvements in peripheral and cerebral oxygenation.TRIAL REGISTRATIONNCT02148692, https://clinicaltrials.gov/ct2

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“…Although over emphasized, concern for APRV settings permeates the literature yet the more conventional approach to ventilator settings such as V T , respiratory rate (RR), and PEEP remains controversial despite decades of research and debate ( Deans et al, 2005 ; Amato et al, 2015 ; Sahetya et al, 2017 ; Algera et al, 2018 ; Costa et al, 2021 ; Goligher et al, 2021 ; Pelosi et al, 2021 ; Abrams et al, 2022 ; Dianti et al, 2022 ). In addition, important elements of mechanical ventilation such as RR, inspiratory time and flows, and expiratory time and flows are generally not reported or ignored–whereas they are essential components of the total energy delivered to the lung ( Gattinoni et al, 2016 ; Bates et al, 2020 ) and the combination of these factors can promote lung healing or injury.…”

Section: Myth #1—airway Pressure Release Ventilation Is Too Difficult...mentioning

confidence: 99%

Myths and Misconceptions of Airway Pressure Release Ventilation: Getting Past the Noise and on to the Signal

et al. 2022

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In the pursuit of science, competitive ideas and debate are necessary means to attain knowledge and expose our ignorance. To quote Murray Gell-Mann (1969 Nobel Prize laureate in Physics): “Scientific orthodoxy kills truth”. In mechanical ventilation, the goal is to provide the best approach to support patients with respiratory failure until the underlying disease resolves, while minimizing iatrogenic damage. This compromise characterizes the philosophy behind the concept of “lung protective” ventilation. Unfortunately, inadequacies of the current conceptual model–that focuses exclusively on a nominal value of low tidal volume and promotes shrinking of the “baby lung” - is reflected in the high mortality rate of patients with moderate and severe acute respiratory distress syndrome. These data call for exploration and investigation of competitive models evaluated thoroughly through a scientific process. Airway Pressure Release Ventilation (APRV) is one of the most studied yet controversial modes of mechanical ventilation that shows promise in experimental and clinical data. Over the last 3 decades APRV has evolved from a rescue strategy to a preemptive lung injury prevention approach with potential to stabilize the lung and restore alveolar homogeneity. However, several obstacles have so far impeded the evaluation of APRV’s clinical efficacy in large, randomized trials. For instance, there is no universally accepted standardized method of setting APRV and thus, it is not established whether its effects on clinical outcomes are due to the ventilator mode per se or the method applied. In addition, one distinctive issue that hinders proper scientific evaluation of APRV is the ubiquitous presence of myths and misconceptions repeatedly presented in the literature. In this review we discuss some of these misleading notions and present data to advance scientific discourse around the uses and misuses of APRV in the current literature.

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Association of Positive End-Expiratory Pressure and Lung Recruitment Selection Strategies with Mortality in Acute Respiratory Distress Syndrome: A Systematic Review and Network Meta-analysis

Cited by 48 publications

References 53 publications

Acute respiratory distress syndrome in adults: diagnosis, outcomes, long-term sequelae, and management

Acute respiratory distress syndrome in adults: diagnosis, outcomes, long-term sequelae, and management

Distribution of ventilation and oxygenation in surgical obese patients ventilated with high versus low positive end-expiratory pressure

Myths and Misconceptions of Airway Pressure Release Ventilation: Getting Past the Noise and on to the Signal

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