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, 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, Karen E A Burns, 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

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.

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. Trials Evaluated During the Systematic…
Figure 1. Trials Evaluated During the Systematic Review of the Literature.
Figure 2. Forest Plot of Hospital Mortality.
Figure 2. Forest Plot of Hospital Mortality.

References

    1. Greenfield LJ, Ebert PA, Benson DW. Effect of positive pressure ventilation on surface tension properties of lung extracts. Anesthesiology. 1964;25:312–16.
    1. Webb HH, Tierney DF. Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressures. Protection by positive end-expiratory pressure. Am Rev Respir Dis. 1974;110:556–65.
    1. Kolobow T, Moretti MP, Fumagalli R, Mascheroni D, Prato P, et al. Severe impairment in lung function induced by high peak airway pressure during mechanical ventilation. Am Rev Respir Dis. 1987;135:312–15.
    1. Meade MO, Cook DJ. The etiology, consequences, and prevention of barotrauma: a critical review of the literature. Clin Intens Care. 1995;6:166–73.
    1. Gattinoni L, Pesenti A, Avalli L, Rossi F, Bombino M. Pressure-volume curve of total respiratory system in acute respiratory failure. Computed tomographic scan trial. Am Rev Respir Dis. 1987;136:730–36.
    1. Hickling KG, Henderson SJ, Jackson R. Low mortality associated with low volume pressure limited ventilation with permissive hypercapnia in severe adult respiratory distress syndrome. Intensive Care Med. 1990;16:372–77.
    1. Hickling KG, Howard R. A retrospective survey of treatment and mortality in aspiration pneumonia. Intensive Care Med. 1988;14:617–22.
    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 trial. Crit Care Med. 1994;22:1568–78.
    1. Marini JJ. Pressure-targeted, lung-protective ventilatory support in acute lung injury. Chest. 1994;105(Supp):109S–14S.
    1. Slutsky AS. Mechanical ventilation. American College of Chest Physicians Consensus Conference. Chest. 1993;104:1833–59.
    1. Kallet RH, Corral W, Silverman HJ, Luce JM. Implementation of a low tidal volume ventilation protocol for patients with acute lung injury or acute respiratory distress syndrome. Respir Care. 2001;46:1024–37.
    1. Feihl F, Perret C. Permissive hypercapnia: How permissive should we be? Am J Respir Crit Care Med. 1994;150:1722–37.
    1. Eichacker PQ, Gerstenberger EP, Banks SM, Cui X, Natanson C. Meta-analysis of acute lung injury and acute respiratory distress syndrome trials tesing low tidal volumes. Am J Respir Crit Care Med. 2002;166:1510–14.
    1. Qin ZQ, Wang C. A meta-analysis of clinical studies of low volume ventilation in ARDS. Zhonghua Yi Xue Za Zhi. 2003;83(3):224–7.
    1. Moran JL, Bersten AD, Solomon PJ. Meta-analysis of controlled trials of ventilation therapy in acute lung injury and the acute respiratory distress syndrome: an alternative perspective. Intensive Care Med. 2005;31:227–35.
    1. Petrucci N, Iacovelli W. Lung Protective Ventilation Strategy for the acute respiratory distress syndrome. Cochrane Database of Systematic Reviews. 2007;18(3):CD003844.
    1. Higgins JPT, Green S, editors. Version 5.0.1 [updated Sept 2008]. The Cochrane Collaboration 2008; Cochrane Handbook of Systematic Reviews of Interventions.
    1. Montori VM, Devereaux PJ, Adhikari NK, Burns KE, Eggert CH, et al. Randomized trials stopped early for benefit: a systematic review. JAMA. 2005;294:2203–09.
    1. Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y, et al. for the GRADE working group. What is “quality of evidence” and why is it important to clinicians? BMJ. 2008;336:995–8.
    1. Kleinbaum DG, Kupper LL, Muller KE. Belmont, Calif: Duxbury; 1988. Applied regression analysis and other multivariable methods. pp. 512–16.
    1. Murray JF, Matthay MA, Luce JM, Flick JR. An expanded definition of the Acute Respiratory Distress Syndrome. Am Rev Respir Dis. 1988;134:720–23.
    1. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818–29.
    1. Der Simonian R, Laird N. Meta-analysis in clinical Trials. Control Clin Trials. 1986;7:177–88.
    1. Cochran W. The combination of estimates from different experiments. Biometrics. 1954;10:101–29.
    1. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21:1539–58.
    1. Higgins JP, Thomson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. Brit Med J. 2003;327:557–60.
    1. Lee PC, Helsmoortel CM, Cohn SM, Fink MP. Are low tidal volumes safe? Chest. 1990;97:425–29.
    1. Rappaport SH, Shpiner R, Yoshihara G, Wright J, Chang P. Randomized, prospective trial of pressure-limited versus volume-controlled ventilation in severe respiratory failure. Crit Care Med. 1994;22:22–32.
    1. Carvalho CRR, Barbas CSV, Medeiros DM, Magaldi RB, Filho GL, et al. Temporal hemodynamic effects of permissive hypercapnia associated with ideal PEEP in ARDS. Am J Respir Crit Care Med. 1997;156:1458–66.
    1. Ranieri VM, Suter PM, Tortorella C, De Tuillio R, Dayer JM, et al. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial. JAMA. 1999;282:54–61.
    1. Esteban A, Alia I, Gordo F, de Pablo R, Suarez J, et al. for the Spanish Lung Failure Collaboration Group. Prospective randomized trial comparing pressure-controlled ventilation and volume-controlled ventilation in ARDS. Chest. 2000;117:1690–96.
    1. Niu T, Chen T, Li P. Comparison of the effects of limited airway pressure with permissive hypercapnic ventilation and ventilation with traditional tactics in patients suffering from acute respiratory distress syndrome. Chinese Crit Care Med. 2000;12:36–8.
    1. Long Y, Liu DW, Zhou X, Liu HZ, Guo ZJ, et al. The application of individualized ventilation strategies in acute respiratory distress syndrome. Zhonghua Jie He He Hu Xi Za Zhi. 2006;29:549–53.
    1. McKinley BA, Moore FA, Sailors RM, Cocanour CS, Marquez A, et al. Computerized decision support for mechanical ventilation of trauma induced ARDS: results of a randomized clinical trial. J Trauma. 2001;50:415–24.
    1. Amato MB, Barbas CS, Medeiros DM, Schettino Gde P, Lorenzi Filho G, et al. Beneficial effects of the “open lung approach” with low distending pressures in acute respiratory distress syndrome. A prospective, randomized study on mechanical ventilation. Am J Respir Crit Care Med. 1995;152(6 Pt1):1835–46.
    1. Wang XZ, Lu CJ, Gao FQ, Li XH, Hao D, et al. Comparison of the effects of BiPAP ventilation combined with lung recruitment maneuvers and low tidal volume AC ventilation in patients with acute respiratory distress syndrome. Chin J Tuberc Respir Dis. 2007;30:44–47.
    1. Wu G, Lu B. The application of low tidal volume pressure-controlled ventilation in patients with acute respiratory distress syndrome. Bull Hunan Med Univ. 1998;23:57–8.
    1. Brochard L, Roudot-Thoraval F, Roupie E, Delclaux C, Chastre J, et al. Tidal volume reduction for prevention of ventilator-induced lung injury in acute respiratory distress syndrome. Am J Respir Crit Care Med. 1998;158:1831–38.
    1. Amato MB, Barbas CSV, Medeiros DM, Magaldi RB, Schettino GP, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338:347–54.
    1. Stewart TE, Meade MO, Cook DJ, Granton JT, Hodder RV, et al. Evaluation of a ventilation strategy to prevent barotrauma in patients at high risk for acute respiratory distress syndrome. N Engl J Med. 1998;338:355–61.
    1. Brower RG, Shanholtz CB, Fessler HE, Shade DM, White P, Jr, et al. Prospective, randomized controlled clinical trial comparing traditional versus reduced tidal volume ventilation in acute respiratory distress syndrome patients. Crit Care Med. 1999;27:1492–98.
    1. East TD, Heermann LK, Bradshaw RL, Lugo A, Sialors RM, et al. Proc AMIA Symp; 1999. Efficacy of computerized decision support for mechanical ventilation: results of a prospective multicenter randomized trial. pp. 251–55.
    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. N Engl J Med. 2000;342:1301–08.
    1. Orme J, Jr, Romney JS, Hopkins RO, Pope D, Chan KJ, et al. Pulmonary function and health-related quality of life in survivors of acute respiratory distress syndrome. Am J Respir Crit Care Med. 2003;167:690–94.
    1. Villar J, Kacmarek RM, Perez-Mendez L, Aguirre-Jaime A. A high positive end-expiratory pressure, low tidal volume ventilatory strategy improves outcome in persistent acute respiratory distress syndrome: a randomized, controlled trial. Crit Care Med. 2006;34:1311–18.
    1. Sun J-J, Yang M-W, Wang C-H, Li C-H, Qin W-H, et al. Clinical effects of low stretch ventilation on acute respiratory distress syndrome. Chin Crit Care Med. 2009;21:209–612.
    1. Le Gall JR, Loirat P, Alperovitch A, Glaser P, Granthil C, et al. A simplified acute physiology score for ICU patients. Crit Care Med. 1984;12:975–77.
    1. Cullen DJ, Civettta JM, Briggs BA, Ferrara LC. Therapeutic intervention scoring system: A method for quantitative comparison of patient care. Crit Care Med. 1974;2:57–60.
    1. Marshall JC, Cook DK, Christou NV, Bernard GR, Sprung CL, et al. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med. 1995;23:1638–52.
    1. Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner M, et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill, hospitalized adults. Chest. 1991;100:1619–36.
    1. Baker SP, O'Neill B, Haddon W, Jr, Long WB. The Injury Severity Score: a method for describing patients with multiple injuries and evaluation emergency care. J Trauma. 1974;14:187–96.
    1. Peto R, Pick MC, Armitage P, Breslow NE, Cox DR, et al. Design and analysis of randomized clinical trials requiring prolonged observation of each patient I. Introduction and design. Br J Cancer. 1977;34:585–612.
    1. Geller NL, Pocock SJ. Interim analysis in randomized clinical trials: ramifications and guides for practitioners. Biometrics. 1987;43:213–23.
    1. Pocock SJ, Hughes MD. Estimation issues in clinical trials and overviews. Stat Med. 1990;9:657–71.
    1. Phoenix SI, Paravastu S, Columb M, Vincent JL, Nirmalan M. Does a Higher Positive End Expiratory Pressure Decrease Mortality in Acute Respiratory Distress Syndrome? A Systematic Review and Meta-analysis. Anesthesiology. 2009;110:1098–1105.
    1. Balk R, Bone RC. The Adult Respiratory Distress Syndrome. Med Clin N America. 1983;67:685–700.
    1. Brun-Buisson C, Minelli C, Bertolini G, Brazzi L, Pimentel J, et al. . ALIVE study Group. Epidemiology and outcome of acute lung injury in European intensive care units. Results from the ALIVE study. Intensive Care Med. 2004;30:51–61.
    1. Gainnier M, Roch A, Forel JM, Thirion X, Arnal JM, et al. Effect of neuromuscular blocking agents on gas exchange in patients presenting with acute respiratory distress syndrome. Crit Care Med. 2004;32:113–19.
    1. Berlin JA, Santanna J, Schmid CH, Szczech LA Feldman HI. Anti-Lymphocyte Antibody Induction Therapy Study Group. Individual patient-versus group-level data meta-regressions for the investigation of treatment effect modifiers: Ecological bias rears its ugly head. Statist Med: 2002;21:371–87.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe