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Meta-Analysis
. 2013 Feb 28;2013(2):CD003844.
doi: 10.1002/14651858.CD003844.pub4.

Lung protective ventilation strategy for the acute respiratory distress syndrome

Nicola Petrucci  1 , Carlo De Feo
Affiliations
Meta-Analysis

Lung protective ventilation strategy for the acute respiratory distress syndrome

Nicola Petrucci et al. Cochrane Database Syst Rev. .

Abstract

Background: Patients with acute respiratory distress syndrome and acute lung injury require mechanical ventilatory support. Acute respiratory distress syndrome and acute lung injury are further complicated by ventilator-induced lung injury. Lung protective ventilation strategies may lead to improved survival. This systematic review is an update of a Cochrane review originally published in 2003 and updated in 2007.

Objectives: To assess the effects of ventilation with lower tidal volume on morbidity and mortality in patients aged 16 years or older affected by acute respiratory distress syndrome and acute lung injury. A secondary objective was to determine whether the comparison between low and conventional tidal volume was different if a plateau airway pressure of greater than 30 to 35 cm H20 was used.

Search methods: In our previous 2007 updated review, we searched databases from inception until 2006. In this third updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL and the Web of Science from 2006 to September 2012. We also updated our search of databases of ongoing research and of reference lists from 2006 to September 2012.

Selection criteria: We included randomized controlled trials comparing ventilation using either a lower tidal volume (Vt) or low airway driving pressure (plateau pressure 30 cm H2O or less), resulting in a tidal volume of 7 ml/kg or less, versus ventilation that used Vt in the range of 10 to 15 ml/kg in adults (16 years old or older) with acute respiratory distress syndrome and acute lung injury.

Data collection and analysis: We independently assessed trial quality and extracted data. Wherever appropriate, results were pooled. We applied fixed-effect and random-effects models.

Main results: We did not find any new study which were eligible for inclusion in this update. The total number of studies remained unchanged, six trials involving 1297 patients. Five trials had a low risk of bias. One trial had an unclear risk of bias. Mortality at day 28 was significantly reduced by lung-protective ventilation with a relative risk (RR) of 0.74 (95% confidence interval (CI) 0.61 to 0.88); hospital mortality was reduced with a RR of 0.80 (95% CI 0.69 to 0.92). Overall mortality was not significantly different if a plateau pressure less than or equal to 31 cm H2O in the control group was used (RR 1.13, 95% CI 0.88 to 1.45). There was insufficient evidence for morbidity and long-term outcomes.

Authors' conclusions: Clinical heterogeneity, such as different lengths of follow up and higher plateau pressure in control arms in two trials, makes the interpretation of the combined results difficult. Mortality was significantly reduced at day 28 and at the end of the hospital stay. The effects on long-term mortality are unknown, although the possibility of a clinically relevant benefit cannot be excluded. Ventilation with lower tidal volumes is becoming a routine strategy of treatment of acute respiratory distress syndrome and acute lung injury, stopping investigators from carrying out additional trials.

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Conflict of interest statement

None known

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Amato 1998 {published data only}
    1. Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Paula Pinto Schettino G, et al. Effect of a protective‐ventilation strategy on mortality in the acute respiratory distress syndrome. New England Journal of Medicine 1998;338:347‐54. - PubMed
ARDS Network 2000 {published data only}
    1. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. New England Journal of Medicine 2000;342:1301‐8. - PubMed
Brochard 1998 {published data only}
    1. Brochard L, Roudot‐Thoraval F, Roupie E, Delclaux C, Chastre J, Fernandez‐Mondejar E, et al. Tidal volume reduction for prevention of ventilator induced lung injury in acute respiratory distress syndrome. The multicenter trial group on tidal volume reduction in ARDS. American Journal of Respiratory and Critical Care Medicine 1998;158:1831‐8. - PubMed
Brower 1999 {published data only}
    1. Brower RG, Shanholtz CB, Fessler HE, Shade DM, White P Jr, Wiener CM, et al. Prospective, randomized controlled clinical trial comparing traditional versus reduced tidal volume ventilation in acute respiratory distress syndrome patients. Critical Care Medicine 1999;27:1492‐8. - PubMed
Stewart 1998 {published data only}
    1. Stewart TE, Meade MO, Cook DJ, Granton JT, Hodder RV, Lapinsky SE, et al. Evaluation of a ventilation strategy to prevent barotrauma in patient at high risk for acute respiratory distress syndrome. Pressure and volume limited ventilation strategy group. New England Journal of Medicine 1998;338:355‐61. - PubMed
Villar 2006 {published data only}
    1. Villar J, Kacmarek RM, Perez‐Mendez L, Aguirre‐Jaime A. A high positive end‐expiration pressure, low tidal volume ventilatory strategy improves outcome in persistent acute respiratory distress syndrome: a randomized, controlled trial. Critical Care Medicine 2006;34(5):1311‐8. - PubMed

References to studies excluded from this review

Brower 2004 {published data only}
    1. Brower RG, Lanken PN, MacIntyre N. Higher versus lower positive end‐expiratory pressures in patients with the acute respiratory distress syndrome. New England Journal of Medicine 2004;351:327‐36. - PubMed
Esteban 2000 {published data only}
    1. Esteban A, Alia I, Gordo F, Pablo R, Suarez J, Gonzales G, et al. Prospective randomized trial comparing pressure‐controlled ventilation and volume‐controlled ventilation in ARDS. For the Spanish Lung Failure Collaborative Group. Chest 2000;117:1690‐6. - PubMed
Meade 2008 {published data only}
    1. Meade MO, Cook DJ, Guyatt GH, Slutsky AS, Arabi YM, Cooper DJ, et al. Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end‐expiratory pressure for acute lung injury and acute respiratory distress syndrome. JAMA 2008;299(6):637‐45. - PubMed
Mercat 2008 {published data only}
    1. Mercat A, Richard JCM, Vielle B, Jaber S, Osman D, Diehl JL, et al. Positive end‐expiratory pressure setting in adult with acute lung injury and acute respiratory distress syndrome. JAMA 2008;299(6):646‐55. - PubMed
Ranieri 1999 {published data only}
    1. Ranieri VM, Suter PM, Tortorella C, Tullio R, Dayer JM, Brienza A, et al. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome. JAMA 1999;282:54‐62. - PubMed
Rappaport 1994 {published data only}
    1. Rappaport SH, Shpiner R, Yoshihara G, Wright J, Chang P, Abraham E. Randomized, prospective trial of pressure‐limited versus volume‐controlled ventilation in severe respiratory failure. Critical Care Medicine 1994;22:22‐32. - PubMed

Additional references

Artigas 1998
    1. Artigas A, Bernard GR, Carlet J. The American‐European Consensus Conference on ARDS, Part 2. Intensive Care Medicine 1998;24:378‐98. - PubMed
Bernard 1994
    1. Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, et al. The American‐European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. American Journal of Respiratory and Critical Care Medicine 1994;149:818‐24. - PubMed
Cooper 1999
    1. Cooper AB, Ferguson ND, Hanly PJ, Meade MO, Kachura JR, Granton JT, et al. Long‐term follow up of survivors of acute lung injury: lack of effect of a ventilation strategy to prevent barotrauma. Critical Care Medicine 1999;27:2616‐21. - PubMed
Davidson 1999
    1. Davidson TA, Caldwell ES, Curtis JR, Hudson LD, Steinberg KP. Reduced quality of life in survivors of acute respiratory distress syndrome compared with critically control patients. JAMA 1999;281:354‐60. - PubMed
Deeks 2001
    1. Deeks JJ, Altman DG, Bradburn MJ. Statistical methods for examining heterogeneity and combining results from several studies in meta‐analysis. In: Egger M, Smith GD, Altman DG editor(s). Systematc Reviews. London: BMJ Books, 2001:285‐312.
Dowdy 2006
    1. Dowdy DW, Eid MP, Dennison CR, Mendez‐Tellez PA, Herridge MS, Guallar E, et al. Quality of life after acute respiratory distress syndrome: a meta‐analysis. Intensive Care Medicine 2006;32:1115‐24. - PubMed
Dreyfuss 1998
    1. Dreyfuss D, Soler P, Basset G, Saumon G. High inflation pressure pulmonary edema. Respective effects of high airway pressure, high tidal volume and positive end‐expiratory pressure. American Review of Respiratory Diseases 1998;137:1159‐64. - PubMed
Eichacker 2002
    1. Eichacker PQ, Gerstenberger EP, Banks SM, Cui X, Natanson C. Meta‐analysis of acute lung injury and acute respiratory distress syndrome trials testing low tidal volumes. American Journal of Respiratory and Critical Care Medicine 2002;166:1510‐4. - PubMed
Esteban 2008
    1. Esteban A, Ferguson ND, Meade MO, Frutos‐Vivar F, Apezteguia C, Brochard L, et al. Evolution of mechanical ventilation in response to clinical research. American Journal of Respiratory and Critical Care Medicine 2008;177:170‐7. - PubMed
Feihl 1994
    1. Feihl F, Perret C. Permissive hypercapnia: how permissive should we be?. American Journal of Respiratory and Critical Care Medicine 1994;150:1722‐37. - PubMed
Frutos‐Vivar 2004
    1. Frutos‐Vivar F, Nin N, Esteban A. Epidemiology of acute lung injury and acute respiratory distress syndrome. Current Opinion in Critical Care 2004;10:1‐6. - PubMed
Gattinoni 1995
    1. Gattinoni L, Pelosi P, Crotti S, Valenza F. Effects of positive end‐expiratory pressure on regional distribution of tidal volume and recruitment in adult respiratory distress syndrome. American Journal of Respiratory and Critical Care Medicine 1995;151:1807‐14. - PubMed
Gattinoni 2002
    1. Gattinoni L, Chiumello D, Russo R. Reduced tidal volumes and lung protective ventilatory strategy: where do we go from here?. Current Opinion in Critical Care 2002;8:45‐50. - PubMed
Hickling 1990
    1. Hickling KG, Henderson SJ, Jackson R. Low mortality associated with volume pressure limited ventilation with permissive hypercapnia in severe adult respiratory distress syndrome. Intensive Care Medicine 1990;16:372‐7. - PubMed
Hickling 1994
    1. Hickling KG, Walsh J, Henderson S, Jackson R. Low mortality rate in adult respiratory distress syndrome using low‐volume, pressure limited ventilation with permissive hypercapnia: a prospective study. Critical Care Medicine 1994;22:1568‐78. - PubMed
Higgins 2002
    1. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta‐analysis. Statistics in Medicine 2002;21:1539‐58. - PubMed
Knaus 1985
    1. Knaus WA, Wagner DP, Draper EA, Zimmerman JE. APACHE II: a severity of disease classification system. Critical Care Medicine 1985;13:818‐29. - PubMed
Knaus 1991
    1. Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner M, Bastos PG, et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 1991;100:1619‐36. - PubMed
Marini 1990
    1. Marini JJ. Lung mechanics in the adult respiratory distress syndrome. Clinical Chest Medicine 1990;11:673‐90. - PubMed
Monchi 1998
    1. Monchi M, Bellenfant F, Cariou A, Joly LM, Thebert D, Laurent I, et al. Early predictive factors of survival in the acute respiratory distress syndrome. A multivariate analysis. American Journal of Respiratory and Critical Care Medicine 1998;158:1076‐81. - PubMed
Murray 1988
    1. Murray JF, Matthay MA, Luce JM, Flick MR. An expanded definition of the adult respiratory distress syndrome. American Review of Respiratory Diseases 1988;138:720‐3. - PubMed
Orme 2003
    1. Orme J, Romney JS, Hopkins RO, Pope D, Chan KJ, Thomsen G, et al. Pulmonary function and health related quality of life in survivors of ARDS. American Journal of Respiratory and Critical Care Medicine 2003;167:690‐4. - PubMed
Petrucci 2003
    1. Petrucci N. Tidal volumes in ARDS and meta‐analysis. American Journal of Respiratory and Critical Care Medicine 2003;167:935‐6. - PubMed
Ranieri 1997
    1. Ranieri VM, Brienza N, Santostasi S, Puntillo F, Mascia L. Impairment of lung and chest wall mechanics in patients with acute respiratory distress syndrome. Role of abdominal distension. American Journal of Respiratory and Critical Care Medicine 1997;156:1082‐91. - PubMed
Ranieri 2012
    1. Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, et al. Acute respiratory distress syndrome: the Berlin definition. JAMA 2012;307(23):2526‐33. - PubMed
Roupie 1999
    1. Roupie E, Lepage E, Wysocki M, Fagon JY, Chastre J, Dreyfuss D, et al. Prevalence, etiologies and outcome of the acute respiratory distress syndrome among hypoxemic ventilated patients. SRLF Collaborative group on mechanical ventilation. Societe de Reanimation de Langue Francaise. Intensive Care Medicine 1999;25:920‐9. - PubMed

References to other published versions of this review

Petrucci 2004a
    1. Petrucci N, Iacovelli W. Ventilation with lower tidal volume versus traditional tidal volumes in adult for acute lung injury and acute respiratory distress syndrome. Cochrane Database of Systematic Reviews 2004, Issue 1. [DOI: 10.1002/14651858.CD003844] - DOI - PubMed
Petrucci 2004b
    1. Petrucci N, Iacovelli W. Ventilation with lower tidal volume. A quantitative systematic review of randomized controlled trials. Anesthesia and Analgesia 2004;99:193‐200. - PubMed
Petrucci 2004c
    1. Petrucci N, Icovelli W. Ventilation with lower tidal volume versus traditional tidal volumes in adults for acute lung injury and acute respiratory distress syndrome. Cochrane Database of Systematic Reviews 2004, Issue 2. [DOI: 10.1002/14651858.CD003844.pub2] - DOI - PubMed
Petrucci 2007
    1. Petrucci N, Iacovelli W. Lung protection ventilation strategy for the acute respiratory distress syndrome. Cochrane Database of Systematic Reviews 2007, Issue 3. [DOI: 10.1002/14651858.CD003844.pub3] - DOI - PubMed

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