Association Between Use of Lung-Protective Ventilation With Lower Tidal Volumes and Clinical Outcomes Among Patients Without Acute Respiratory Distress Syndrome A Meta-analysis

Department of Critical Care Medicine, ABC Medical School, Santo André, São Paulo, Brazil.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 10/2012; 308(16):1651-9. DOI: 10.1001/jama.2012.13730
Source: PubMed


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.
To determine whether use of lower tidal volumes is associated with improved outcomes of patients receiving ventilation who do not have ARDS.
MEDLINE, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials up to August 2012.
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.
Three reviewers extracted data on study characteristics, methods, and outcomes. Disagreement was resolved by consensus.
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.
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.

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    • "All tracheal intubations should have their position confirmed with waveform capnography in addition to auscultation [2,34,35]. Protective lung ventilation including tidal volumes of 6-8 ml/kg, plateau pressures less than 30cmH20, optimal PEEP and titrated FiO2 should be initiated as soon as possible in all critically ill patients [59,60]. In patients with a neurological insult, neuro-protective ventilation with tight PaCO2 control (4.5-5kPa) and a PaO2 greater than 10kPa may be appropriate [61]. "
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