Christian Putensen, MD, PhD; Nils Theuerkauf, MD; Jörg Zinserling, PhD; Hermann Wrigge, MD, PhD; Paolo Pelosi, MD
Potential Conflicts of Interest: None disclosed.
Reproducible Research Statement:Study protocol and data set: Not available. Statistical code: Available from Dr. Zinserling (e-mail, firstname.lastname@example.org).
Requests for Single Reprints: Christian Putensen, MD, PhD, Department of Anaesthesiology and Intensive Care Medicine, University of Bonn, Sigmund-Freud-Strasse 25, 53105 Bonn, Germany; e-mail, email@example.com.
Current Author Addresses: Drs. Putensen, Theuerkauf, Zinserling, and Wrigge: Department of Anaesthesiology and Intensive Care Medicine, University of Bonn, Sigmund-Freud-Strasse 25, 53105 Bonn, Germany.
Dr. Pelosi: Department of Ambient, Health, and Safety, University of Insubria, Servizio di Anestesia B, Ospedale di Circolo e Fondazione Macchi viale Borri 57, 21100 Varese, Italy.
Author Contributions: Conception and design: C. Putensen, P. Pelosi.
Analysis and interpretation of the data: C. Putensen, N. Theuerkauf, J. Zinserling, H. Wrigge, P. Pelosi.
Drafting of the article: C. Putensen, P. Pelosi.
Critical revision of the article for important intellectual content: C. Putensen, P. Pelosi.
Final approval of the article: C. Putensen, P. Pelosi.
Provision of study materials or patients: C. Putensen.
Statistical expertise: J. Zinserling.
Obtaining of funding: C. Putensen.
Administrative, technical, or logistic support: C. Putensen.
Collection and assembly of data: C. Putensen, N. Theuerkauf, J. Zinserling, H. Wrigge, P. Pelosi.
Putensen C, Theuerkauf N, Zinserling J, Wrigge H, Pelosi P. Meta-analysis: Ventilation Strategies and Outcomes of the Acute Respiratory Distress Syndrome and Acute Lung Injury. Ann Intern Med. 2009;151:566-576. doi: 10.7326/0003-4819-151-8-200910200-00011
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Published: Ann Intern Med. 2009;151(8):566-576.
Trials have provided conflicting results regarding the effect of different ventilatory strategies on the outcomes of patients with the acute respiratory distress syndrome (ARDS) and acute lung injury.
To determine whether ventilation with low tidal volume (Vt) and limited airway pressure or higher positive end-expiratory pressure (PEEP) improves outcomes for patients with ARDS or acute lung injury.
Multiple computerized databases (through March 2009), reference lists of identified articles, and queries of principal investigators. No language restrictions were applied.
Randomized, controlled trials (RCTs) reporting mortality and comparing lower versus higher Vt ventilation, lower versus higher PEEP, or a combination of both in adults with ARDS or acute lung injury.
Using a standard protocol, 2 reviewer teams assessed trial eligibility and abstracted data on quality of study design and conduct, population characteristics, intervention, co-interventions, and confounding variables.
4 RCTs tested lower versus higher Vt ventilation at similar PEEP in 1149 patients, 3 RCTs compared lower versus higher PEEP at low Vt ventilation in 2299 patients, and 2 RCTs compared a combination of higher Vt and lower PEEP ventilation versus lower Vt and higher PEEP ventilation in 148 patients. Lower Vt ventilation reduced hospital mortality (odds ratio, 0.75 [95% CI, 0.58 to 0.96]; P = 0.02) compared with higher Vt ventilation at similar PEEP. Higher PEEP did not reduce hospital mortality (odds ratio, 0.86 [CI, 0.72 to 1.02]; P = 0.08) compared with lower PEEP using low Vt ventilation. Higher PEEP reduced the need for rescue therapy to prevent life-threatening hypoxemia (odds ratio, 0.51 [CI, 0.36 to 0.71]; P < 0.001) and death (odds ratio, 0.51 [CI, 0.36 to 0.71]; P < 0.001) in patients receiving rescue therapies.
Pooling according to similar ventilatory strategies resulted in few RCTs analyzed in each group. The benefit of low Vt is derived from only 1 study.
Available evidence from a limited number of RCTs shows better outcomes with routine use of low Vt but not high PEEP ventilation in unselected patients with ARDS or acute lung injury. High PEEP may help to prevent life-threatening hypoxemia in selected patients.
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Emergency Medicine, Pulmonary/Critical Care, Acute Respiratory Distress Syndrome/Acute Lung Injury.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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