Effects of alveolar recruitment maneuvers on clinical outcomes in patients with acute respiratory distress syndrome: a systematic review and meta-analysis

Suzumura, Érica Aranha; Figueiró, Mabel; Normílio-Silva, Karina; Laranjeira, Lígia Nasi; Oliveira, Cláudia Cardoso de; Buehler, Anna Maria; Bugano, Diogo Diniz Gomes; Amato, Marcelo Britto Passos; Carvalho, Carlos Roberto Ribeiro de; Berwanger, Otávio; Cavalcanti, Alexandre Biasi

doi:10.1007/s00134-014-3413-6

Cited by 96 publications

(62 citation statements)

References 37 publications

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“…However, several meta-analyses of therapeutic trials involving lung-protective ventilation in conjunction with PP, 13 higher PEEP, 183 neuromuscular blocking agent, 184 and recruitment maneuvers 185 suggest that these individual therapies improve outcomes in the most severe cohort of ARDS subjects. Since 2006, we have instituted a bundled approach using lung-protective ventilation with PP, aerosolized prostacyclin, and a variation of a previously described recruitment maneuver (pressure control ventilation with super-PEEP) 186 in dire circumstances of refractory ARDS.…”

Section: Inhaled Vasodilatorsmentioning

confidence: 99%

A Comprehensive Review of Prone Position in ARDS

2015

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Prone position (PP) has been used since the 1970s to treat severe hypoxemia in patients with ARDS because of its effectiveness at improving gas exchange. Compared with the supine position (SP), placing patients in PP effects a more even tidal volume distribution, in part, by reversing the vertical pleural pressure gradient, which becomes more negative in the dorsal regions. PP also improves resting lung volume in the dorsocaudal regions by reducing the superimposed pressure of both the heart and the abdomen. In contrast, pulmonary perfusion remains preferentially distributed to the dorsal lung regions, thus improving overall alveolar ventilation/perfusion relationships. 1660RESPIRATORY CARE • NOVEMBER 2015 VOL 60 NO 11Moreover, the larger tissue mass suspended from a wider dorsal chest wall effects a more homogeneous distribution of pleural pressures throughout the lung that reduces abnormal strain and stress development. This is believed to ameliorate the severity or development of ventilator-induced lung injury and may partly explain why PP reduces mortality in severe ARDS. Over 40 years of clinical trials have consistently reported improved oxygenation in approximately 70% of subjects with ARDS. Early initiation of PP is more likely to improve oxygenation than initiation during the subacute phase. Maximal oxygenation improvement occurs over a wide time frame ranging from several hours to several days. Meta-analyses of randomized controlled trials suggest that PP provides a survival advantage only in patients with relatively severe ARDS (P aO 2 /F IO 2 <150 mm Hg). Moreover, survival is enhanced when patients are managed with a smaller tidal volume (<8 mL/kg), higher PEEP (10 -13 cm H 2 O), and longer duration of PP sessions (>10 -12 h/session). Combining adjunctive therapies (high PEEP, recruitment maneuvers, and inhaled vasodilators) with PP has an additive effect in improving oxygenation and may be particularly helpful in stabilizing gas exchange in very severe ARDS.

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Section: Inhaled Vasodilatorsmentioning

confidence: 99%

A Comprehensive Review of Prone Position in ARDS

2015

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“…Suzumura et al 53 conducted a meta-analysis to assess the effects of recruitment maneuvers on clinical outcomes in subjects with ARDS. Their review identified 10 randomized controlled trials of 1,594 subjects.…”

Section: The Evidencementioning

confidence: 99%

Recruitment Maneuvers and PEEP Titration

2015

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The injurious effects of alveolar overdistention are well accepted, and there is little debate regarding the importance of pressure and volume limitation during mechanical ventilation. The role of recruitment maneuvers is more controversial. Alveolar recruitment is desirable if it can be achieved, but the potential for recruitment is variable among patients with ARDS. A stepwise recruitment maneuver, similar to an incremental PEEP titration, is favored over sustained inflation recruitment maneuvers. Many approaches to PEEP titration have been proposed, and the best method to choose the most appropriate level for an individual patient is unclear. A PEEP level should be selected that balances alveolar recruitment against overdistention. The easiest approach to select PEEP might be according to the severity of the disease: 5-10 cm H 2 O PEEP in mild ARDS, 10 -15 cm H 2 O PEEP in moderate ARDS, and 15-20 cm H 2 O PEEP in severe ARDS. Recruitment maneuvers and PEEP should be used within the context of lung protection and not just as a means of improving oxygenation.

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“…The degree of lung recruitment versus overdistension afforded by increasing PEEP may vary considerably between patients, by volume history, and with use of recruitment maneuvers, influencing whether increasing PEEP is lung-protective for an individual [44–46]. At a minimum, future PEEP titration trials should incorporate measures of lung recruitability, overdistension, and heterogeneity (stress raisers) [47] to permit pre-specified subgroup analyses testing for an interaction with study arm.…”

Section: Individualizing Managementmentioning

confidence: 99%

Personalized medicine for ARDS: the 2035 research agenda

et al. 2016

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Survival from ARDS has increased substantially in the last twenty years as a result of key advances in lung-protective ventilation and resuscitation. Similarly, clinical practice improvements have contributed to an impressive decline in nosocomial ARDS incidence. Personalizing mechanical ventilation for further lung protection is a top research priority for the years ahead. However, the ARDS research agenda must be broader in scope. The clinical syndrome of ARDS includes a heterogeneous assemblage of pathophysiological processes leading to lung injury. Further understanding of these varied, complex biological underpinnings of ARDS pathogenesis is needed to inform therapeutic discovery and tailor management strategy to the individual patient. While some therapies may be applicable broadly to all ARDS patients, others may benefit only certain biologically distinct subsets. The twenty-year ARDSne(x)t research agenda calls for bringing personalized medicine to ARDS, asking simultaneously both whether a treatment affords clinically meaningful benefit and for whom. This expanded scope necessitates acquisition of highly granular biological, physiological, and clinical data as the new standard across studies. Tremendous investment in research infrastructure and global collaboration will be vital to fulfilling this agenda.

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Effects of alveolar recruitment maneuvers on clinical outcomes in patients with acute respiratory distress syndrome: a systematic review and meta-analysis

Abstract: Although ARMs may decrease the mortality of patients with ARDS without increasing the risk for major adverse events, current evidence is not definitive. Large-scale ongoing trials addressing this question may provide data better applicable to clinical practice.

Cited by 96 publications

References 37 publications

A Comprehensive Review of Prone Position in ARDS

A Comprehensive Review of Prone Position in ARDS

Recruitment Maneuvers and PEEP Titration

Personalized medicine for ARDS: the 2035 research agenda

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