Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis.

CONTEXT Lung-protective mechanical ventilation with the use of lower tidal volumes has been found to improve outcomes of patients with acute respiratory distress syndrome (ARDS). It has been suggested that use of lower tidal volumes also benefits patients who do not have ARDS. OBJECTIVE To determine whether use of lower tidal volumes is associated with improved outcomes of patients receiving ventilation who do not have ARDS. DATA SOURCES MEDLINE, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials up to August 2012. STUDY SELECTION Eligible studies evaluated use of lower vs higher tidal volumes in patients without ARDS at onset of mechanical ventilation and reported lung injury development, overall mortality, pulmonary infection, atelectasis, and biochemical alterations. DATA EXTRACTION Three reviewers extracted data on study characteristics, methods, and outcomes. Disagreement was resolved by consensus. DATA SYNTHESIS Twenty articles (2822 participants) were included. Meta-analysis using a fixed-effects model showed a decrease in lung injury development (risk ratio [RR], 0.33; 95% CI, 0.23 to 0.47; I2, 0%; number needed to treat [NNT], 11), and mortality (RR, 0.64; 95% CI, 0.46 to 0.89; I2, 0%; NNT, 23) in patients receiving ventilation with lower tidal volumes. The results of lung injury development were similar when stratified by the type of study (randomized vs nonrandomized) and were significant only in randomized trials for pulmonary infection and only in nonrandomized trials for mortality. Meta-analysis using a random-effects model showed, in protective ventilation groups, a lower incidence of pulmonary infection (RR, 0.45; 95% CI, 0.22 to 0.92; I2, 32%; NNT, 26), lower mean (SD) hospital length of stay (6.91 [2.36] vs 8.87 [2.93] days, respectively; standardized mean difference [SMD], 0.51; 95% CI, 0.20 to 0.82; I2, 75%), higher mean (SD) PaCO2 levels (41.05 [3.79] vs 37.90 [4.19] mm Hg, respectively; SMD, -0.51; 95% CI, -0.70 to -0.32; I2, 54%), and lower mean (SD) pH values (7.37 [0.03] vs 7.40 [0.04], respectively; SMD, 1.16; 95% CI, 0.31 to 2.02; I2, 96%) but similar mean (SD) ratios of PaO2 to fraction of inspired oxygen (304.40 [65.7] vs 312.97 [68.13], respectively; SMD, 0.11; 95% CI, -0.06 to 0.27; I2, 60%). Tidal volume gradients between the 2 groups did not influence significantly the final results. CONCLUSIONS Among patients without ARDS, protective ventilation with lower tidal volumes was associated with better clinical outcomes. Some of the limitations of the meta-analysis were the mixed setting of mechanical ventilation (intensive care unit or operating room) and the duration of mechanical ventilation.

[1]  Arthur S Slutsky,et al.  Acute Respiratory Distress Syndrome The Berlin Definition , 2012 .

[2]  F. Lellouche,et al.  High Tidal Volumes in Mechanically Ventilated Patients Increase Organ Dysfunction after Cardiac Surgery , 2012, Anesthesiology.

[3]  Z. Tran,et al.  Intraoperative ventilation: incidence and risk factors for receiving large tidal volumes during general anesthesia , 2011, BMC anesthesiology.

[4]  D. Dreyfuss,et al.  Ventilator-induced lung injury: historical perspectives and clinical implications , 2011, Annals of intensive care.

[5]  V. Novack,et al.  Influence of low tidal volume ventilation on time to extubation in cardiac surgical patients. , 2011, Anesthesiology.

[6]  C. Yi,et al.  Does a protective ventilation strategy reduce the risk of pulmonary complications after lung cancer surgery?: a randomized controlled trial. , 2011, Chest.

[7]  J. Marini Spontaneously regulated vs. controlled ventilation of acute lung injury/acute respiratory distress syndrome , 2011, Current opinion in critical care.

[8]  G. Friedman,et al.  Mechanical ventilation with high tidal volume induces inflammation in patients without lung disease , 2010, Critical care.

[9]  Torben Martinussen,et al.  A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial , 2010, The Lancet.

[10]  J. Korevaar,et al.  Ventilation with lower tidal volumes as compared with conventional tidal volumes for patients without acute lung injury: a preventive randomized controlled trial , 2010, Critical care.

[11]  D. Schroeder,et al.  Comparison of two ventilatory strategies in elderly patients undergoing major abdominal surgery. , 2010, British journal of anaesthesia.

[12]  J. Tschopp,et al.  Impact of intraoperative lung-protective interventions in patients undergoing lung cancer surgery , 2009, Critical care.

[13]  X. Bai,et al.  [Effects of the lung protective ventilatory strategy on proinflammatory cytokine release during one-lung ventilation]. , 2008, Ai zheng = Aizheng = Chinese journal of cancer.

[14]  B. Thompson,et al.  Effects of a clinical trial on mechanical ventilation practices in patients with acute lung injury. , 2008, American journal of respiratory and critical care medicine.

[15]  Gordon H Guyatt,et al.  GrADe : what is “ quality of evidence ” and why is it important to clinicians ? rATING quALITY of evIDeNCe AND STreNGTH of reCommeNDATIoNS , 2022 .

[16]  Robert J Gallop,et al.  Potential reasons why physicians underuse lung-protective ventilation: a retrospective cohort study using physician documentation. , 2008, Respiratory care.

[17]  R. Lutter,et al.  Lung epithelial injury markers are not influenced by use of lower tidal volumes during elective surgery in patients without preexisting lung injury. , 2008, American journal of physiology. Lung cellular and molecular physiology.

[18]  Paolo Pelosi,et al.  Evolution of mechanical ventilation in response to clinical research. , 2008, American journal of respiratory and critical care medicine.

[19]  D. Asch,et al.  Harnessing the power of default options to improve health care. , 2007, The New England journal of medicine.

[20]  M. Kuiper,et al.  Mechanical ventilation with lower tidal volumes does not influence the prescription of opioids or sedatives , 2007, Critical care.

[21]  M. Keegan,et al.  Toward the prevention of acute lung injury: Protocol-guided limitation of large tidal volume ventilation and inappropriate transfusion* , 2007, Critical care medicine.

[22]  Arthur S Slutsky,et al.  What Tidal Volumes Should Be Used in Patients without Acute Lung Injury? , 2007, Anesthesiology.

[23]  H. Cai,et al.  Effect of low tidal volume ventilation on atelectasis in patients during general anesthesia: a computed tomographic scan. , 2007, Journal of clinical anesthesia.

[24]  L. Papazian,et al.  Protective Ventilation Influences Systemic Inflammation after Esophagectomy: A Randomized Controlled Study , 2006, Anesthesiology.

[25]  M. Keegan,et al.  Intraoperative Tidal Volume as a Risk Factor for Respiratory Failure after Pneumonectomy , 2006, Anesthesiology.

[26]  F. Jardin Tidal volume reduction in patients with acute lung injury when plateau pressures are not high. , 2006, American journal of respiratory and critical care medicine.

[27]  D. Hager,et al.  Tidal volume reduction in patients with acute lung injury when plateau pressures are not high. , 2005, American journal of respiratory and critical care medicine.

[28]  Andrés Esteban,et al.  Acute respiratory distress syndrome: Underrecognition by clinicians and diagnostic accuracy of three clinical definitions* , 2005, Critical care medicine.

[29]  M. Ernst,et al.  Mechanical ventilation strategies and inflammatory responses to cardiac surgery: a prospective randomized clinical trial , 2005, Intensive Care Medicine.

[30]  V. Ranieri,et al.  Mechanical ventilation affects inflammatory mediators in patients undergoing cardiopulmonary bypass for cardiac surgery: a randomized clinical trial. , 2005, The Journal of thoracic and cardiovascular surgery.

[31]  Ognjen Gajic,et al.  Ventilator settings as a risk factor for acute respiratory distress syndrome in mechanically ventilated patients , 2005, Intensive Care Medicine.

[32]  Gary Nieman,et al.  Dynamic alveolar mechanics and ventilator-induced lung injury , 2005, Critical care medicine.

[33]  Arthur S Slutsky,et al.  Ventilator-induced lung injury: from the bench to the bedside , 2005, Intensive Care Medicine.

[34]  P. Sandercock,et al.  Effect of intravenous corticosteroids on death within 14 days in 10 008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial , 2004, The Lancet.

[35]  J. S. St. Sauver,et al.  Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation* , 2004, Critical care medicine.

[36]  Arthur S Slutsky,et al.  Ventilator-induced lung injury and multiple system organ failure: a critical review of facts and hypotheses , 2004, Intensive Care Medicine.

[37]  G. Rubenfeld,et al.  Barriers to providing lung-protective ventilation to patients with acute lung injury , 2004, Critical care medicine.

[38]  C. Putensen,et al.  The Effects of Different Ventilatory Settings on Pulmonary and Systemic Inflammatory Responses During Major Surgery , 2004, Anesthesia and analgesia.

[39]  J. Bion,et al.  Epidemiology and outcome of acute lung injury in European intensive care units. Results from the ALIVE study. , 2004, Intensive care medicine.

[40]  G. Çetin,et al.  Effects of protective and conventional mechanical ventilation on pulmonary function and systemic cytokine release after cardiopulmonary bypass , 2004, Intensive Care Medicine.

[41]  Salvador Benito,et al.  Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. , 2002, JAMA.

[42]  M J Tobin,et al.  Advances in mechanical ventilation. , 2001, The New England journal of medicine.

[43]  T. Similowski,et al.  VENTILATOR INDUCED LUNG INJURY AND INFECTION IN THE CRITICALLY ILL , 2001 .

[44]  M. Chaney,et al.  Protective ventilation attenuates postoperative pulmonary dysfunction in patients undergoing cardiopulmonary bypass. , 2000, Journal of cardiothoracic and vascular anesthesia.

[45]  D. Schoenfeld,et al.  Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. , 2000, The New England journal of medicine.

[46]  C. Carvalho,et al.  Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. , 1998, The New England journal of medicine.

[47]  D. Dreyfuss,et al.  Ventilator-induced lung injury: lessons from experimental studies. , 1998, American journal of respiratory and critical care medicine.

[48]  M. Lamy,et al.  The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. , 1994, American journal of respiratory and critical care medicine.

[49]  M. Fink,et al.  Are low tidal volumes safe? , 1990, Chest.