Recruitment maneuver does not provide any mortality benefit over lung protective strategy ventilation in adult patients with acute respiratory distress syndrome: a meta-analysis and systematic review of the randomized controlled trials

Abstract

BackgroundClinical benefits of recruitment maneuver in ARDS patients are controversial. A number of previous studies showed possible benefits; a large recent study reported that recruitment maneuver and PEEP titration may even be harmful. This meta-analysis was designed to compare the clinical utility of recruitment maneuver with low tidal volume ventilation in adult patients with ARDS.MethodsRandomized controlled trials comparing recruitment maneuver and lung protective ventilation strategy with lung protective strategy ventilation protocol alone in adult patients with ARDS has been included in this meta-analysis. PubMed and Cochrane Central Register of Controlled Trials were searched from inception to 10 November 2017 to identify potentially eligible trials. Pooled risk ratio (RR) and standardized mean difference (SMD) were calculated for binary and continuous variables respectively.ResultsData of 2480 patients from 7 randomized controlled trials have been included in this meta-analysis and systemic review. Reported mortality at the longest available follow-up [RR (95% CI) 0.93 (0.80, 1.08); p = 0.33], ICU mortality [RR (95% CI) 0.91 (0.76, 1.10); p = 0.33] and in-hospital mortality [RR (95% CI) 0.95 (0.83, 1.08); p = 0.45] were similar between recruitment maneuver group and standard lung protective ventilation group. Duration of hospital stay [SMD (95% CI) 0.00 (− 0.09, 0.10); p = 0.92] and duration of ICU stays [SMD (95% CI) 0.05 (− 0.09, 0.19); p = 0.49] were also similar between recruitment maneuver group and standard lung protective ventilation group. Risk of barotrauma was also similar.ConclusionUse of recruitment maneuver along with co-interventions such as PEEP titration does not provide any benefit in terms of mortality, length of ICU, and hospital stay in ARDS patients.Electronic supplementary materialThe online version of this article (10.1186/s40560-018-0305-9) contains supplementary material, which is available to authorized users.

Effect of lung recruitment maneuver on oxygenation, physiological parameters and mortality in acute respiratory distress syndrome patients: a systematic review and meta-analysis

“…Only six trials were included in the meta-analysis of Goligher et al [15], which could explain that it had not reached the Required Information Size to conclude with a high level of certainty, unlike our analysis ( Fig. 2c) and the meta-analysis of Bhattacharjee et al [16]. Contrary to the meta-analysis of Bhattacharjee et al [16] in which the studies performed without protective ventilation were excluded, we aimed to perform a global overview of LRM in ARDS management (Table 1), even if standards of care for ARDS have changed since the earliest trials.…”

“…2c) and the meta-analysis of Bhattacharjee et al [16]. Contrary to the meta-analysis of Bhattacharjee et al [16] in which the studies performed without protective ventilation were excluded, we aimed to perform a global overview of LRM in ARDS management (Table 1), even if standards of care for ARDS have changed since the earliest trials. To overcome this bias, we conducted a cumulative meta-analysis for the primary outcome, 28-day mortality (Fig.…”

“…Clinical practice guidelines have provided conditional recommendation suggesting the use of LRM in adult patients with ARDS [12,13] while others did not recommend LRM [14]. Two recent meta-analyses [15,16] have shown discrepancies, one [15] suggesting a positive effect of LRM on mortality in ARDS patients, while the other [16] did not find a significant difference on mortality between a LRM strategy and a no-LRM strategy. However, since the publication of the two last meta-analyses, additional recent randomized controlled trials (RCTs) (including ART, PHARLAP and LIVE Studies) [17][18][19] have been published in 2017 and 2019.…”

A Physiologically Informed Strategy to Effectively Open, Stabilize, and Protect the Acutely Injured Lung

“…However, multiple RCTs testing the OLA in ARDS patients have failed to show significant benefits over standard of care (Brower et al, 2004;Meade et al, 2008;Mercat et al, 2008;Cavalcanti et al, 2017;Hodgson et al, 2019). Reasons for these failures include the following: (1) timing of OLA application [early (Borges et al, 2006) vs. late (Gattinoni et al, 2006)] (2) onesize-fits-all RM strategies, (3) PEEP set inappropriately to keep the recruited lung open, (4) recruiting pressures insufficient to open all of the lung, (5) a patient population of responders (lung recruits) and non-responders (lung does not recruit) (Gattinoni et al, 2006), and (6) application of OLA not as a continuous treatment but rather as a one-time event with a long time period before a second application or with no second application at all (Goligher et al, 2017;Lu et al, 2017;Bhattacharjee et al, 2018;Cui et al, 2019;Hodgson et al, 2019;Kang et al, 2019;van der Zee and Gommers, 2019;Zheng et al, 2019). Most (Bhattacharjee et al, 2018;Cui et al, 2019;Hodgson et al, 2019;Kang et al, 2019;Zheng et al, 2019) but not all (Goligher et al, 2017;Lu et al, 2017) meta-analyses have shown no decrease in ARDS-related mortality associated with the OLA.…”

“…Of course the strategy of "casting" the broken lung open until it heals would be clinically effective only with a ventilation strategy that could perform such a feat (Nieman et al, 2018). Unfortunately, the current OLA strategies have not been shown effective at opening and stabilizing the lung (Bhattacharjee et al, 2018;Cui et al, 2019;Hodgson et al, 2019;Kang et al, 2019;Zheng et al, 2019), and the recent ART trial showed an increase in FIGURE 10 | Left -Subpleural alveoli seen using in vivo microscopy in a rat hemorrhagic shock-induced ARDS model ventilated with volume cycled ventilation (VC; A,B) or airway pressure release ventilation (APRV) using the time controlled adaptive ventilation (TCAV) method (APRV; C,D). Individual alveoli are shown by arrows.…”