Introduction
Methods
Data sources and search strategies
Study selection
Inclusion criteria
Exclusion criteria
Quality assessment
Data extraction
Data analysis and statistical methods
Results
Search results
Trial characteristics and methodological quality
Trial | Gattinoni et al., 2001[19] | Guerin et al., 2004[14] | Voggenreiter et al., 2005[20] | Curley et al., 2005[18] | Mancebo et al., 2006[21] | Chan et al., 2007[22] | Fernandez et al., 2008[23] | Taccone et al., 2009[24] | Guérin et al., 2013[13] |
---|---|---|---|---|---|---|---|---|---|
Design | RCT | RCT | RCT | RCT | RCT | RCT | RCT | RCT | RCT |
P/F for enrollment (mmHg) | 300 | 300 | 300 | 300 | 200 | 300 | 300 | 200 | 150 |
Total number of included patients | 304 | 791 | 40 | 101 | 136 | 22 | 40 | 342 | 466 |
PEEP level (cmH2O) | 9 | 7 | 11 | 9 | 12 | 13 | 11 | 11 | 10 |
Duration of PP (h/day) | 7.0 | 8.5 | 11 | 20 | 17 | 24 | ≥20 | ≥20 | 17 |
Vt (ml/kg) | 10 | 8 | 6-8 | 7 | 8 | 7 | 7 | 7 | 6 |
28- to 30-day mortality in P/F ≤ 100 mmHg group (P (n/N), S (n/N)) | NAb | NA | NA | NA | 22/43, 21/29 | NA | NA | 28/74, 35/76 | 25/121, 41/121 |
28- to 30-day mortality in 100 ≤ P/F < 200 mmHg group (P (n/N), S (n/N)) | NA | NA | NA | NA | 11/33, 14/31 | NA | NA | 24/94, 22/98 | 13/116, 34/108 |
28- to 30-day mortality in P/F ≤ 300 mmHg group (P (n/N), S (n/N)) | 74/152, 70/152 | 134/413, 119/378 | NA | 4/51, 4/50 | 30/76, 32/60 | 7/11, 7/11 | NA | 52/168, 57/174 | 38/237, 75/229 |
60-day mortality in P/F ≤ 300 mmHg group (P (n/N), S (n/N)) | 95/152, 89/152 | NA | NA | NA | 22/76, 28/60 | NA | 8/21, 10/19 | 79/168, 91/174 | NA |
90-day mortality in P/F ≤ 300 mmHg group (P (n/N), S (n/N)) | 89/152, 84/152 | 179/413, 159/377 | 1/21, 3/19 | NA | NA | NA | NA | NA | 56/237, 94/229 |
ICU mortality in P/F ≤ 300 mmHg group (P (n/N), S (n/N)) | 77/152, 73/152 | NA | NA | NA | 33/76, 35/60 | NA | NA | 64/168, 73/174 | NA |
Quantitative data synthesis
PP decreased mortality in severe ARDS, but not in mild to moderate ARDS
PP reduced 60-day and 90-day mortality in ARDS patients ventilated with relatively high PEEP
PP reduced 28-day to 30-day mortality when PP duration was longer than 12 hours/day
Discussion
Conclusions
Key messages
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Patients with severe ARDS (defined as P/F ratio ≤100 mmHg) clearly benefit from PP.
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There is no demonstrated benefit of PP in patients with mild to moderate ARDS.
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Patients ventilated with a higher PEEP level (defined as PEEP ≥10 cmH2O) also benefit from PP. Because the results of this study do not allow a definitive explanation for these findings, no firm recommendations can be made regarding the use of PP based on PEEP level.
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In this study, we show that the PP duration matters. It is unclear whether this importance resulted from a dose response to PP or whether there existed a threshold daily PP duration that was required to obtain a benefit. The data suggest, however, that PP for <12 h/day is less likely to be beneficial to patients.