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. 2019 Apr 4;9(1):44.
doi: 10.1186/s13613-019-0518-7.

Airway pressure release ventilation during acute hypoxemic respiratory failure: a systematic review and meta-analysis of randomized controlled trials

Andrea Carsetti  1 , Elisa Damiani  2 , Roberta Domizi  3 , Claudia Scorcella  3 , Simona Pantanetti  3 , Stefano Falcetta  3 , Abele Donati  2 , Erica Adrario  2
Affiliations

Airway pressure release ventilation during acute hypoxemic respiratory failure: a systematic review and meta-analysis of randomized controlled trials

Andrea Carsetti et al. Ann Intensive Care. .

Abstract

Background: Airway pressure release ventilation (APRV) has been considered a tempting mode of ventilation during acute respiratory failure within the concept of open lung ventilation. We performed a systematic review and meta-analysis to verify whether adult patients with hypoxemic respiratory failure have a higher number of ventilator-free days at day 28 when ventilated in APRV compared to conventional ventilation strategy. Secondary outcomes were difference in PaO2/FiO2 at day 3, ICU length of stay (LOS), ICU and hospital mortality, mean arterial pressure (MAP), risk of barotrauma and level of sedation. We searched MEDLINE, Scopus and Cochrane Central Register of Controlled Trials database until December 2018.

Results: We considered five RCTs for the analysis enrolling a total of 330 patients. For ventilatory-free day at day 28, the overall mean difference (MD) between APRV and conventional ventilation was 6.04 days (95%CI 2.12, 9.96, p = 0.003; I2 = 65%, p = 0.02). Patients treated with APRV had a lower ICU LOS than patients treated with conventional ventilation (MD 3.94 days [95%CI 1.44, 6.45, p = 0.002; I2 = 37%, p = 0.19]) and a lower hospital mortality (RD 0.16 [95%CI 0.02, 0.29, p = 0.03; I2 = 0, p = 0.5]). PaO2/FiO2 at day 3 was not different between the two groups (MD 40.48 mmHg [95%CI - 25.78, 106.73, p = 0.23; I2 = 92%, p < 0.001]). MAP was significantly higher during APRV (MD 5 mmHg [95%CI 1.43, 8.58, p = 0.006; I2 = 0%, p = 0.92]). Then, there was no difference regarding the onset of pneumothorax under the two ventilation strategies (RR 1.94 [95%CI 0.54, 6.94, p = 0.31; I2 = 0%, p = 0.74]). ICU mortality and sedation level were not included into quantitative analysis.

Conclusion: This study showed a higher number of ventilator-free days at 28 day and a lower hospital mortality in acute hypoxemic patients treated with APRV than conventional ventilation, without any negative hemodynamic impact or higher risk of barotrauma. However, these results need to be interpreted with caution because of the low-quality evidence supporting them and the moderate heterogeneity found. Other well-designed RCTs need to be conducted to confirm our findings.

Keywords: Acute respiratory distress syndrome; Acute respiratory failure; Airway pressure release ventilation; Meta-analysis.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flowchart of study selection
Fig. 2
Fig. 2
Ventilator-free days at day 28. APRV airway pressure release ventilation, CV conventional ventilation
Fig. 3
Fig. 3
ICU LOS. APRV airway pressure release ventilation, CV conventional ventilation
Fig. 4
Fig. 4
Hospital mortality. APRV airway pressure release ventilation, CV conventional ventilation
Fig. 5
Fig. 5
PaO2/FiO2 at day 3. APRV airway pressure release ventilation, CV conventional ventilation
Fig. 6
Fig. 6
MAP at day 3. APRV airway pressure release ventilation, CV conventional ventilation
Fig. 7
Fig. 7
Barotrauma. APRV airway pressure release ventilation, CV conventional ventilation
See this image and copyright information in PMC

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