Lung ventilation strategies for acute respiratory distress syndrome: a systematic review and network meta-analysis

Changsong Wang, Xiaoyang Wang, Chunjie Chi, Libo Guo, Lei Guo, Nana Zhao, Weiwei Wang, Xin Pi, Bo Sun, Ailing Lian, Jinghui Shi, Enyou Li, Changsong Wang, Xiaoyang Wang, Chunjie Chi, Libo Guo, Lei Guo, Nana Zhao, Weiwei Wang, Xin Pi, Bo Sun, Ailing Lian, Jinghui Shi, Enyou Li

Abstract

To identify the best lung ventilation strategy for acute respiratory distress syndrome (ARDS), we performed a network meta-analysis. The Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, CINAHL, and the Web of Science were searched, and 36 eligible articles were included. Compared with higher tidal volumes with FiO2-guided lower positive end-expiratory pressure [PEEP], the hazard ratios (HRs) for mortality were 0.624 (95% confidence interval (CI) 0.419-0.98) for lower tidal volumes with FiO2-guided lower PEEP and prone positioning and 0.572 (0.34-0.968) for pressure-controlled ventilation with FiO2-guided lower PEEP. Lower tidal volumes with FiO2-guided higher PEEP and prone positioning had the greatest potential to reduce mortality, and the possibility of receiving the first ranking was 61.6%. Permissive hypercapnia, recruitment maneuver, and low airway pressures were most likely to be the worst in terms of all-cause mortality. Compared with higher tidal volumes with FiO2-guided lower PEEP, pressure-controlled ventilation with FiO2-guided lower PEEP and lower tidal volumes with FiO2-guided lower PEEP and prone positioning ventilation are associated with lower mortality in ARDS patients. Lower tidal volumes with FiO2-guided higher PEEP and prone positioning ventilation and lower tidal volumes with pressure-volume (P-V) static curve-guided individual PEEP are potential optimal strategies for ARDS patients.

Figures

Figure 1. Flow diagram of the literature…
Figure 1. Flow diagram of the literature search.
Figure 2. Network of the comparisons for…
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) randomized to receive the treatment. The width of the lines is proportional to the number of trials (beside the line) comparing the connected treatments.
Figure 3. Hazard ratios for death in…
Figure 3. Hazard ratios for death in the Bayesian network meta-analysis versus B.
CI = credible interval for Bayesian network meta-analysis. Hazard ratios (HRs) estimated from random effects, Bayesian network meta-analysis. *95% CI does not contain 1.
Figure 4. Ranking of treatments in terms…
Figure 4. Ranking of treatments in terms of all-cause mortality benefit and incidence of barotraumas.
The probability ranking represents only a possibility without certainty; combining the direct and indirect evidence analysis on overall mortality has more reference significance.

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