The effect of the pressure-volume curve for positive end-expiratory pressure titration on clinical outcomes in acute respiratory distress syndrome: a systematic review

J Steven Hata; Kei Togashi; Avinash B Kumar; Linda D Hodges; Eric F Kaiser; Paul B Tessmann; Christopher A Faust; Daniel I Sessler

doi:10.1177/0885066613488747

The effect of the pressure-volume curve for positive end-expiratory pressure titration on clinical outcomes in acute respiratory distress syndrome: a systematic review

J Intensive Care Med. 2014 Nov-Dec;29(6):348-56. doi: 10.1177/0885066613488747. Epub 2013 Jul 11.

Authors

J Steven Hata¹, Kei Togashi², Avinash B Kumar³, Linda D Hodges⁴, Eric F Kaiser⁵, Paul B Tessmann⁶, Christopher A Faust⁷, Daniel I Sessler⁸

Affiliations

¹ Departments of Outcomes Research, Cardiac Anesthesiology, and General Anesthesiology, Center for Critical Care, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA Department of Cardiac Anesthesiology, Center for Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA Department of General Anesthesiology, Center for Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA hataj@ccf.org.
² Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
³ Division of Critical Care in the Department of Anesthesia, University of Vanderbilt, Nashville, TN, USA.
⁴ Imperial Drive, O'Fallon, MO, USA.
⁵ Department of Cardiac Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
⁶ Division of Cardiothoracic Surgery, University of Florida; Gainesville, FL, USA.
⁷ Department of Anesthesiology, University of Iowa, Iowa City, IA, USA.
⁸ Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.

PMID: 23855040
DOI: 10.1177/0885066613488747

Abstract

Purpose: Methods to optimize positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS) remain controversial despite decades of research. The pressure-volume curve (PVC), a graphical ventilator relationship, has been proposed for prescription of PEEP in ARDS. Whether the use of PVC's improves survival remains unclear.

Methods: In this systematic review, we assessed randomized controlled trials (RCTs) comparing PVC-guided treatment with conventional PEEP management on survival in ARDS based on the search of the National Library of Medicine from January 1, 1960, to January 1, 2010, and the Cochrane Central Register of Controlled Trials. Three RCTs were identified with a total of 185 patients, 97 with PVC-guided treatment and 88 with conventional PEEP management.

Results: The PVC-guided PEEP was associated with an increased probability of 28-day or hospital survival (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.5, 4.9) using a random-effects model without significant heterogeneity (I (2) test: P = .75). The PVC-guided ventilator support was associated with reduced cumulative risk of mortality (-0.24 (95% CI -0.38, -0.11). The PVC-managed patients received greater PEEP (standardized mean difference [SMD] 5.7 cm H2O, 95% CI 2.4, 9.0) and lower plateau pressures (SMD -1.2 cm H2O, 95% CI -2.2, -0.2), albeit with greater hypercapnia with increased arterial pCO2 (SMD 8 mm Hg, 95% CI 2, 14). Weight-adjusted tidal volumes were significantly lower in PVC-guided than conventional ventilator management (SMD 2.6 mL/kg, 95% CI -3.3, -2.0).

Conclusion: This analysis supports an association that ventilator management guided by the PVC for PEEP management may augment survival in ARDS. Nonetheless, only 3 randomized trials have addressed the question, and the total number of patients remains low. Further outcomes studies appear required for the validation of this methodology.

Keywords: acute respiratory distress syndrome; mechanical ventilation; positive end expiratory pressure; systematic review.

Publication types

Research Support, Non-U.S. Gov't
Review
Systematic Review

MeSH terms

Critical Care / methods*
Humans
Length of Stay / statistics & numerical data*
Oxygen Consumption
Positive-Pressure Respiration* / instrumentation
Positive-Pressure Respiration* / mortality
Randomized Controlled Trials as Topic
Respiratory Distress Syndrome / mortality
Respiratory Distress Syndrome / therapy*
Survival Analysis
Tidal Volume
Treatment Outcome
Ventilator-Induced Lung Injury / mortality
Ventilator-Induced Lung Injury / prevention & control*