Does tidal volume challenge improve the feasibility of pulse pressure variation in patients mechanically ventilated at low tidal volumes? A systematic review and meta-analysis

Xiaoying Wang, Shuai Liu, Ju Gao, Yang Zhang, Tianfeng Huang, Xiaoying Wang, Shuai Liu, Ju Gao, Yang Zhang, Tianfeng Huang

Abstract

Background: Pulse pressure variation (PPV) has been widely used in hemodynamic assessment. Nevertheless, PPV is limited in low tidal volume ventilation. We conducted this systematic review and meta-analysis to evaluate whether the tidal volume challenge (TVC) could improve the feasibility of PPV in patients ventilated at low tidal volumes.

Methods: PubMed, Embase and Cochrane Library inception to October 2022 were screened for diagnostic researches relevant to the predictability of PPV change after TVC in low tidal volume ventilatory patients. Summary receiving operating characteristic curve (SROC), pooled sensitivity and specificity were calculated. Subgroup analyses were conducted for possible influential factors of TVC.

Results: Ten studies with a total of 429 patients and 457 measurements were included for analysis. The predictive performance of PPV was significantly lower than PPV change after TVC in low tidal volume, with mean area under the receiving operating characteristic curve (AUROC) of 0.69 ± 0.13 versus 0.89 ± 0.10. The SROC of PPV change yielded an area under the curve of 0.96 (95% CI 0.94, 0.97), with overall pooled sensitivity and specificity of 0.92 (95% CI 0.83, 0.96) and 0.88 (95% CI 0.76, 0.94). Mean and median cutoff value of the absolute change of PPV (△PPV) were 2.4% and 2%, and that of the percentage change of PPV (△PPV%) were 25% and 22.5%. SROC of PPV change in ICU group, supine or semi-recumbent position group, lung compliance less than 30 cm H2O group, moderate positive end-expiratory pressure (PEEP) group and measurements devices without transpulmonary thermodilution group yielded 0.95 (95%0.93, 0.97), 0.95 (95% CI 0.92, 0.96), 0.96 (95% CI 0.94, 0.97), 0.95 (95% CI 0.93, 0.97) and 0.94 (95% CI 0.92, 0.96) separately. The lowest AUROCs of PPV change were 0.59 (95% CI 0.31, 0.88) in prone position and 0.73 (95% CI 0.60, 0.84) in patients with spontaneous breathing activity.

Conclusions: TVC is capable to help PPV overcome limitations in low tidal volume ventilation, wherever in ICU or surgery. The accuracy of TVC is not influenced by reduced lung compliance, moderate PEEP and measurement tools, but TVC should be cautious applied in prone position and patients with spontaneous breathing activity. Trial registration PROSPERO (CRD42022368496). Registered on 30 October 2022.

Keywords: Change; Fluid responsiveness; Low tidal volume; Pulse pressure variation; Tidal volume challenge.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2023. The Author(s).

Figures

Fig. 1
Fig. 1
Concept of TVC and PPV change. TVC tidal volume challenge, △PPV absolute change of pulse pressure variation, △PPV% percentage change of pulse pressure variation, Vt tidal volume, T1 measurement time point before TVC, T2 measurement time point after the TVC start, PBW predicted body weight
Fig. 2
Fig. 2
Flow of studies selection
Fig. 3
Fig. 3
Risk of bias and applicability concerns for the studies included in the meta-analysis. a Risk of bias graph. b Risk of bias summary
Fig. 4
Fig. 4
Summary receiver operating characteristic curve for the change of pulse pressure variation after tidal volume challenge predicting fluid responsiveness in low tidal volume ventilation. The diamond is the summary point representing the average sensitivity and specificity estimates. AUC area under the curve, SENS sensitivity, SPEC specificity, SROC summary receiver operating characteristics. The ellipses around this summary point are the 95% confidence region (dashed line) and the 95% prediction region (dotted line)
Fig. 5
Fig. 5
Sensitivity and specificity of the change of pulse pressure variation after tidal volume challenge predicting fluid responsiveness in low tidal volume ventilation for all data. Each solid square represents an individual study. Error bars represent 95% CI
Fig. 6
Fig. 6
Scatter plot of cutoff value of △PPV and △PPV% in included studies. The purple black dots represent absolute change of pulse pressure variation (△PPV). The black diamond squares represent percentage change of pulse pressure variation (△PPV%). The cutoff values of △PPV are as follows: (1) Myatra 2017 [14], 3.5%; (2) Jun 2019 [16], 1%; (3) Elsayed 2021 [19], 3.5%; (4) Taccheri 2021 [20], 1%; Hamzaoui2021 [21]; (5) Shi 2022 [22], 3.5%; (6) Xu 2022 [23], 2%. The cutoff values of △PPV% are as follows: (1) Myatra 2017 [14], 48%; (2)Yonis 2017 [15], 29%; (3) Jun 2019 [16], 25%; (4) Messina 2019 [17], 13.3%; (5) Messina 2020 [18], 12%; (6) Taccheri 2021 [20], 20%;
Fig. 7
Fig. 7
Deeks’ funnel plot with superimposed regression line. P value for slope coefficient is 0.27, which is greater than 0.05, suggesting the symmetry of the studies and the low likelihood of publication bias
Fig. 8
Fig. 8
Study research string. TVC tidal volume challenge, △PPV absolute change of pulse pressure variation, △PPV% percentage change of pulse pressure variation, TPTD transpulmonary thermodilution, PEEP positive end-expiratory pressure

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