Mechanical ventilation modes for respiratory distress syndrome in infants: a systematic review and network meta-analysis

Abstract

Introduction: The effects of different mechanical ventilation (MV) modes on mortality outcome in infants with respiratory distress syndrome (RDS) are not well known.

Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, EMBASE, MEDLINE, CINAHL, and Web of Science for studies published through April 2014 that assessed mortality in infants with RDS given different MV modes. We assessed studies for eligibility, extracted data, and subsequently pooled the data. A Bayesian fixed-effects model was used to combine direct comparisons with indirect evidence. We also performed sensitivity analyses and rankings of the competing treatment modes.

Results: In total, 20 randomized controlled trials were included for the network meta-analysis, which consisted of 2,832 patients who received one of 16 ventilation modes. Compared with synchronized intermittent mandatory ventilation (SIMV) + pressure support ventilation (PSV), time-cycled pressure-limited ventilation (TCPL) (hazard ratio (HR) 0.290; 95% confidence interval (CI) 0.071 to 0.972), high-frequency oscillatory ventilation (HFOV) (HR 0.294; 95% CI 0.080 to 0.852), SIMV + volume-guarantee (VG) (HR 0.122; 95% CI 0.014 to 0.858), and volume-controlled (V-C) (HR 0.139; 95% CI 0.024 to 0.677) ventilation modes are associated with lower mortality. The combined results of available ventilation modes were not significantly different in regard to the incidences of patent ductus arteriosus and intraventricular hemorrhage.

Conclusion: Compared with the SIMV + PSV ventilation mode, the TCPL, HFOV, SIMV + VG, and V-C ventilation modes are associated with lower mortality.

Figure 1

Flow diagram of the literature search.

Figure 2

Network of the comparisons for the Bayesian network meta-analysis. The size of the nodes is proportional to the number of patients (in parentheses) randomly assigned to receive the treatment. The width of the lines is proportional to the number of trials (next to the line) that compare the connected treatments. A/C, assist-control ventilation; A/C + VG, assist-control plus volume-guarantee ventilation; A/C + VG + RM, assist-control plus volume-guarantee ventilation with recruitment maneuver; CMV, continuous mandatory ventilation; HFFIV, high-frequency flow interrupted ventilation; HFJV, high-frequency jet ventilation; HFOV, high-frequency oscillatory ventilation; IMV, intermittent mandatory ventilation; PSV, pressure support ventilation; PSV + VG, pressure support ventilation with volume-guarantee ventilation; PTV, patient-triggered ventilation; SIMV, synchronized intermittent mechanical ventilation; SIMV + PSV, synchronized intermittent mechanical ventilation with pressure support ventilation; SIMV + VG, synchronized intermittent mechanical ventilation with volume-guarantee ventilation; SIPPV + VG, synchronized intermittent positive pressure ventilation plus volume-guarantee ventilation; V-C, volume-controlled (through adjusting the delivered tidal volume).

Figure 3

Hazard ratios for death in the Bayesian network meta-analysis versus SIMV + PSV. Hazard ratios are estimated from a fixed-effects Bayesian network meta-analysis. *95% confidence interval (CI) for the Bayesian network meta-analysis does not contain 1. A/C, assist-control ventilation; A/C + VG, assist-control plus volume-guarantee ventilation; A/C + VG + RM, assist-control plus volume-guarantee ventilation with recruitment maneuver; CMV, continuous mandatory ventilation; HFFIV, high-frequency flow interrupted ventilation; HFJV, high-frequency jet ventilation; HFOV, high-frequency oscillatory ventilation; IMV, intermittent mandatory ventilation; PSV, pressure support ventilation; PSV + VG, pressure support ventilation with volume-guarantee ventilation; PTV, patient-triggered ventilation; SIMV, synchronized intermittent mechanical ventilation; SIMV + PSV, synchronized intermittent mechanical ventilation with pressure support ventilation; SIMV + VG, synchronized intermittent mechanical ventilation with volume-guarantee ventilation; SIPPV + VG, synchronized intermittent positive pressure ventilation plus volume-guarantee ventilation; V-C, volume-controlled (through adjusting the delivered tidal volume).

Figure 4

Hazard ratios for death in the Bayesian network meta-analysis versus high-frequency jet ventilation (HFJV). Hazard ratios are estimated from a fixed-effects Bayesian network meta-analysis. *95% confidence interval (CI) for the Bayesian network meta-analysis does not contain 1. A/C, assist-control ventilation; A/C + VG, assist-control plus volume-guarantee ventilation; A/C + VG + RM, assist-control plus volume-guarantee ventilation with recruitment maneuver; CMV, continuous mandatory ventilation; HFFIV, high-frequency flow interrupted ventilation; HFOV, high-frequency oscillatory ventilation; IMV, intermittent mandatory ventilation; PSV, pressure support ventilation; PSV + VG, pressure support ventilation with volume-guarantee ventilation; PTV, patient-triggered ventilation; SIMV, synchronized intermittent mechanical ventilation; SIMV + PSV, synchronized intermittent mechanical ventilation with pressure support ventilation; SIMV + VG, synchronized intermittent mechanical ventilation with volume-guarantee ventilation; SIPPV + VG, synchronized intermittent positive pressure ventilation plus volume-guarantee ventilation; V-C, volume-controlled (through adjusting the delivered tidal volume).

Figure 5

Hazard ratios for death in the Bayesian network meta-analysis versus patient-triggered ventilation (PTV). Hazard ratios are estimated from a fixed-effects Bayesian network meta-analysis. *95% confidence interval (CI) for Bayesian network meta-analysis does not contain 1. A/C, assist-control ventilation; A/C + VG, assist-control plus volume-guarantee ventilation; A/C + VG + RM, assist-control plus volume-guarantee ventilation with recruitment maneuver; CMV, continuous mandatory ventilation; HFFIV, high-frequency flow interrupted ventilation; HFJV, high-frequency jet ventilation; HFOV, high-frequency oscillatory ventilation; IMV, intermittent mandatory ventilation; PSV, pressure support ventilation; PSV + VG, pressure support ventilation with volume-guarantee ventilation; SIMV, synchronized intermittent mechanical ventilation; SIMV + PSV, synchronized intermittent mechanical ventilation with pressure support ventilation; SIMV + VG, synchronized intermittent mechanical ventilation with volume-guarantee ventilation; SIPPV + VG, synchronized intermittent positive pressure ventilation plus volume-guarantee ventilation; V-C, volume-controlled (through adjusting the delivered tidal volume).