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Meta-Analysis
. 2011 Jan 28;6(1):e14623.
doi: 10.1371/journal.pone.0014623.

Pressure and volume limited ventilation for the ventilatory management of patients with acute lung injury: a systematic review and meta-analysis

Karen E A Burns  1 , Neill K J Adhikari, Arthur S Slutsky, Gordon H Guyatt, Jesus Villar, Haibo Zhang, Qi Zhou, Deborah J Cook, Thomas E Stewart, Maureen O Meade
Affiliations
Meta-Analysis

Pressure and volume limited ventilation for the ventilatory management of patients with acute lung injury: a systematic review and meta-analysis

Karen E A Burns et al. PLoS One. .

Abstract

Background: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are life threatening clinical conditions seen in critically ill patients with diverse underlying illnesses. Lung injury may be perpetuated by ventilation strategies that do not limit lung volumes and airway pressures. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing pressure and volume-limited (PVL) ventilation strategies with more traditional mechanical ventilation in adults with ALI and ARDS.

Methods and findings: We searched Medline, EMBASE, HEALTHSTAR and CENTRAL, related articles on PubMed™, conference proceedings and bibliographies of identified articles for randomized trials comparing PVL ventilation with traditional approaches to ventilation in critically ill adults with ALI and ARDS. Two reviewers independently selected trials, assessed trial quality, and abstracted data. We identified ten trials (n = 1,749) meeting study inclusion criteria. Tidal volumes achieved in control groups were at the lower end of the traditional range of 10-15 mL/kg. We found a clinically important but borderline statistically significant reduction in hospital mortality with PVL [relative risk (RR) 0.84; 95% CI 0.70, 1.00; p = 0.05]. This reduction in risk was attenuated (RR 0.90; 95% CI 0.74, 1.09, p = 0.27) in a sensitivity analysis which excluded 2 trials that combined PVL with open-lung strategies and stopped early for benefit. We found no effect of PVL on barotrauma; however, use of paralytic agents increased significantly with PVL (RR 1.37; 95% CI, 1.04, 1.82; p = 0.03).

Conclusions: This systematic review suggests that PVL strategies for mechanical ventilation in ALI and ARDS reduce mortality and are associated with increased use of paralytic agents.

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Conflict of interest statement

Competing Interests: Drs. Burns, Adhikari, Zhang and Zhou have no known or perceived conflicts of interest to declare, including specific financial interests or relationships or affiliations relevant to the subject of the manuscript. Drs. Slutsky, Meade, Guyatt, Stewart and Cook coauthored one of the trials included in this review. Dr. Villar was the first author of a separate randomized trial included in this review. This does not alter the authors' adherence to all the PLoS ONE policies on sharing data and materials.

Figures

Figure 1
Figure 1. Trials Evaluated During the Systematic Review of the Literature.
Figure 2
Figure 2. Forest Plot of Hospital Mortality.
See this image and copyright information in PMC

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