The application of prone positioning for acute respiratory distress syndrome (ARDS) has evolved, with recent trials focusing on patients with more severe ARDS, and applying prone ventilation for more ...prolonged periods.
This review evaluates the effect of prone positioning on 28-day mortality (primary outcome) compared with conventional mechanical ventilation in the supine position for adults with ARDS.
We updated the literature search from a systematic review published in 2010, searching MEDLINE, EMBASE, and CENTRAL (through to August 2016). We included randomized, controlled trials (RCTs) comparing prone to supine positioning in mechanically ventilated adults with ARDS, and conducted sensitivity analyses to explore the effects of duration of prone ventilation, concurrent lung-protective ventilation and ARDS severity. Secondary outcomes included Pa
/Fi
ratio on Day 4 and an evaluation of adverse events. Meta-analyses used random effects models. Methodologic quality of the RCTs was evaluated using the Cochrane risk of bias instrument, and methodologic quality of the overall body of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) guidelines.
Eight RCTs fulfilled entry criteria, and included 2,129 patients (1,093 51% proned). Meta-analysis revealed no difference in mortality (risk ratio RR, 0.84; 95% confidence interval CI, 0.68-1.04), but subgroup analyses found lower mortality with 12 hours or greater duration prone (five trials; RR, 0.74; 95% CI, 0.56-0.99) and for patients with moderate to severe ARDS (five trials; RR, 0.74; 95% CI, 0.56-0.99). Pa
/Fi
ratio on Day 4 for all patients was significantly higher in the prone positioning group (mean difference, 23.5; 95% CI, 12.4-34.5). Prone positioning was associated with higher rates of endotracheal tube obstruction and pressure sores. Risk of bias was low across the trials.
Prone positioning is likely to reduce mortality among patients with severe ARDS when applied for at least 12 hours daily.
In this issue of the journal, Belhaj and colleagues (pp. 584-595) evaluated the effects of his CKD (tacrolimus) preconditioning in a randomized experimental porcine model of brain death-induced lung ...injury. Researchers administered intravenous tacrolimus (n=8) or placebo (n=9) before infusing autologous blood to induce brain death. They measured hemodynamic changes up to 7 hours after brain death and analyzed histological features of post-euthanasia lung tissue. The authors observed that tacrolimus pretreatment was associated with beneficial hemodynamic effects and reversed many other detrimental effects of brain death. (i.e., prevented a decline in the ratio of PaO2 to FiO2), decreased circulating inflammatory markers (i.e., IL-6 to IL-10 ratio, IL-1β ratio), and improved pulmonary endothelium integrity. improved. (ie, B. vascular cell adhesion molecule)-1, a glycocalyx-derived molecule) and lung histology (ie, decreased inflammatory and apoptotic cells). Despite these encouraging results, there was no difference in lung injury scores (ie, cellular infiltration, edema, hemorrhage, and a composite marker of airway epithelial damage). The authors speculate that tacrolimus therapy did not completely eliminate the effects of systemic inflammation on donor lungs, highlighting the potential of combination therapy.
Sud et al. discuss the comparative effectiveness of protective ventilation strategies for moderate and severe acute respiratory distress syndrome. The authors performed a network meta-analysis of ...randomized trials. They analyzed 34 trials including 9,085 adults with primarily moderate-to-severe ARDS (median baseline PaO2/FiO2, 118; interquartile range, 110-143). Their findings suggest that combining low Vt with prone ventilation is associated with the greatest reduction in mortality for critically ill adults with moderate-to-severe ARDS.
In this trial, high-frequency oscillatory ventilation was compared with conventional ventilation with a lung-protective protocol. When the study was stopped early, hospital mortality was 47% with ...HFOV versus 35% with the control ventilation strategy.
The acute respiratory distress syndrome (ARDS) is a common complication of critical illness.
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Mortality is high, and survivors often have long-term complications.
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Although mechanical ventilation is life-sustaining for patients with ARDS, it can perpetuate lung injury. Basic research suggests that repetitive overstretching or collapse of lung units with each respiratory cycle can generate local and systemic inflammation, contributing to multiorgan failure and death.
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Consistent with these findings are data from clinical trials that support the use of smaller tidal volumes (6 vs. 12 ml per kilogram of predicted body weight)
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and higher levels of positive end-expiratory pressure (PEEP). . . .
Randomized trials investigating neuromuscular blocking agents in adult acute respiratory distress syndrome (ARDS) have been inconclusive about effects on mortality, which is very high in this ...population. Uncertainty also exists about the associated risk of ICU-acquired weakness.
We conducted a systematic review and meta-analysis. We searched the Cochrane (Central) database, MEDLINE, EMBASE, ACP Journal Club, and clinical trial registries for randomized trials investigating survival effects of neuromuscular blocking agents in adults with ARDS. Two independent reviewers abstracted data and assessed methodologic quality. Primary study investigators provided additional unpublished data.
Three trials (431 patients; 20 centers; all from the same research group in France) met inclusion criteria for this review. All trials assessed 48-hour infusions of cisatracurium besylate. Short-term infusion of cisatracurium besylate was associated with lower hospital mortality (RR, 0.72; 95% CI, 0.58 to 0.91; P=0.005; I2=0). This finding was robust on sensitivity analyses. Neuromuscular blockade was also associated with lower risk of barotrauma (RR, 0.43; 95% CI, 0.20 to 0.90; P=0.02; I2=0), but had no effect on the duration of mechanical ventilation among survivors (MD, 0.25 days; 95% CI, 5.48 to 5.99; P=0.93; I2=49%), or the risk of ICU-acquired weakness (RR, 1.08; 95% CI, 0.83 to 1.41; P=0.57; I2=0). Primary studies lacked protracted measurements of weakness.
Short-term infusion of cisatracurium besylate reduces hospital mortality and barotrauma and does not appear to increase ICU-acquired weakness for critically ill adults with ARDS.
Community-acquired pneumonia (CAP) is common and often severe.
To examine the effect of adjunctive corticosteroid therapy on mortality, morbidity, and duration of hospitalization in patients with ...CAP.
MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through 24 May 2015.
Randomized trials of systemic corticosteroids in hospitalized adults with CAP.
Two reviewers independently extracted study data and assessed risk of bias. Quality of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation system by consensus among the authors.
The median age was typically in the 60s, and approximately 60% of patients were male. Adjunctive corticosteroids were associated with possible reductions in all-cause mortality (12 trials; 1974 patients; risk ratio RR, 0.67 95% CI, 0.45 to 1.01; risk difference RD, 2.8%; moderate certainty), need for mechanical ventilation (5 trials; 1060 patients; RR, 0.45 CI, 0.26 to 0.79; RD, 5.0%; moderate certainty), and the acute respiratory distress syndrome (4 trials; 945 patients; RR, 0.24 CI, 0.10 to 0.56; RD, 6.2%; moderate certainty). They also decreased time to clinical stability (5 trials; 1180 patients; mean difference, -1.22 days CI, -2.08 to -0.35 days; high certainty) and duration of hospitalization (6 trials; 1499 patients; mean difference, -1.00 day CI, -1.79 to -0.21 days; high certainty). Adjunctive corticosteroids increased frequency of hyperglycemia requiring treatment (6 trials; 1534 patients; RR, 1.49 CI, 1.01 to 2.19; RD, 3.5%; high certainty) but did not increase frequency of gastrointestinal hemorrhage.
There were few events and trials for many outcomes. Trials often excluded patients at high risk for adverse events.
For hospitalized adults with CAP, systemic corticosteroid therapy may reduce mortality by approximately 3%, need for mechanical ventilation by approximately 5%, and hospital stay by approximately 1 day.
None.
This document provides evidence-based clinical practice guidelines on the use of mechanical ventilation in adult patients with acute respiratory distress syndrome (ARDS).
A multidisciplinary panel ...conducted systematic reviews and metaanalyses of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations.
For all patients with ARDS, the recommendation is strong for mechanical ventilation using lower tidal volumes (4-8 ml/kg predicted body weight) and lower inspiratory pressures (plateau pressure < 30 cm H
O) (moderate confidence in effect estimates). For patients with severe ARDS, the recommendation is strong for prone positioning for more than 12 h/d (moderate confidence in effect estimates). For patients with moderate or severe ARDS, the recommendation is strong against routine use of high-frequency oscillatory ventilation (high confidence in effect estimates) and conditional for higher positive end-expiratory pressure (moderate confidence in effect estimates) and recruitment maneuvers (low confidence in effect estimates). Additional evidence is necessary to make a definitive recommendation for or against the use of extracorporeal membrane oxygenation in patients with severe ARDS.
The panel formulated and provided the rationale for recommendations on selected ventilatory interventions for adult patients with ARDS. Clinicians managing patients with ARDS should personalize decisions for their patients, particularly regarding the conditional recommendations in this guideline.
The call for meaningful patient and family engagement in health care and research is gaining impetus. Healthcare institutions and research funding agencies increasingly encourage clinicians and ...researchers to work actively with patients and their families to advance clinical care and research. Engagement is increasingly mandated by healthcare organizations and is becoming a prerequisite for research funding. In this article, we review the rationale and the current state of patient and family engagement in patient care and research in the ICU. We identify opportunities to strengthen engagement in patient care by promoting greater patient and family involvement in care delivery and supporting their participation in shared decision-making. We also identify challenges related to patient willingness to engage, barriers to participation, participant risks, and participant expectations. To advance engagement, clinicians and researchers can develop the science behind engagement in the ICU context and demonstrate its impact on patient- and process-related outcomes. In addition, we provide practical guidance on how to engage, highlight features of successful engagement strategies, and identify areas for future research. At present, enormous opportunities remain to enhance engagement across the continuum of ICU care and research.
Objective To evaluate the effect of oral decontamination on the incidence of ventilator associated pneumonia and mortality in mechanically ventilated adults.Design Systematic review and ...meta-analysis.Data sources Medline, Embase, CINAHL, the Cochrane Library, trials registers, reference lists, conference proceedings, and investigators in the specialty.Review methods Two independent reviewers screened studies for inclusion, assessed trial quality, and extracted data. Eligible trials were randomised controlled trials enrolling mechanically ventilated adults that compared the effects of daily oral application of antibiotics or antiseptics with no prophylaxis.Results 11 trials totalling 3242 patients met the inclusion criteria. Among four trials with 1098 patients, oral application of antibiotics did not significantly reduce the incidence of ventilator associated pneumonia (relative risk 0.69, 95% confidence interval 0.41 to 1.18). In seven trials with 2144 patients, however, oral application of antiseptics significantly reduced the incidence of ventilator associated pneumonia (0.56, 0.39 to 0.81). When the results of the 11 trials were pooled, rates of ventilator associated pneumonia were lower among patients receiving either method of oral decontamination (0.61, 0.45 to 0.82). Mortality was not influenced by prophylaxis with either antibiotics (0.94, 0.73 to 1.21) or antiseptics (0.96, 0.69 to 1.33) nor was duration of mechanical ventilation or stay in the intensive care unit.Conclusions Oral decontamination of mechanically ventilated adults using antiseptics is associated with a lower risk of ventilator associated pneumonia. Neither antiseptic nor antibiotic oral decontamination reduced mortality or duration of mechanical ventilation or stay in the intensive care unit.
This analysis of previously reported trials shows that low tidal volumes, a key component of safer ventilation strategies, confer a protective effect against complications only if the lower volume ...results in a lower pulmonary driving pressure.
Mechanical-ventilation strategies that use lower end-inspiratory (plateau) airway pressures, lower tidal volumes (V
T
), and higher positive end-expiratory pressures (PEEPs) — collectively termed lung-protective strategies — have been associated with survival benefits in randomized clinical trials involving patients with the acute respiratory distress syndrome (ARDS).
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The different components of lung protection in those strategies, such as lower V
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, lower plateau pressure, and higher PEEP, can all reduce mechanical stresses on the lung, which are thought to induce ventilator-induced lung injury.
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Clinical trials, however, have reported conflicting responses to the manipulation of separate components of lung . . .
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