Division of Critical Care, Department of Medicine, Trillium Health Partners-University of Toronto, Mississauga, Ontario, Canada.
Institute of Better Health, Trillium Health Partners, Mississauga, Ontario, Canada.
Am J Respir Crit Care Med. 2021 Jun 1;203(11):1366-1377. doi: 10.1164/rccm.202008-3039OC.
Choosing the best ventilation strategy for acute respiratory distress syndrome (ARDS) is complex, yet it is highly relevant to clinicians during a respiratory pandemic. To compare the effects of low Vt, high Vt, high positive end-expiratory pressure (PEEP), prone ventilation, high-frequency oscillation, and venovenous extracorporeal membrane oxygenation (VV ECMO) on mortality in ARDS. We performed a network meta-analysis of randomized trials. We applied the Grading of Recommendations Assessment, Development and Evaluation methodology to discern the relative effect of interventions on mortality. We analyzed 34 trials including 9,085 adults with primarily moderate-to-severe ARDS (median baseline Pa/Fi, 118; interquartile range, 110-143). Prone positioning combined with low Vt was the best strategy (risk ratio [RR], 0.74 [95% confidence interval (CI), 0.60-0.92] vs. low Vt; high certainty). VV ECMO was also rated among the best (RR, 0.78 [95% CI, 0.58-1.05] vs. low Vt; RR, 0.66; [95% CI, 0.49-0.88] vs. high Vt) but was rated with lower certainty because VV ECMO was restricted to very severe ARDS (mean baseline Pa/Fi<75). High PEEP combined with low Vt was rated intermediately (RR, 0.91 [95% CI, 0.81-1.03] vs. low Vt; low certainty; RR, 0.77 [95% CI, 0.65-0.91] vs. high Vt; moderate certainty). High Vt was rated worst (RR, 1.19 [95% CI, 1.02-1.37] vs. low Vt; moderate certainty), and we found no support for high-frequency oscillation or high Vt with prone ventilation. These 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.
选择急性呼吸窘迫综合征（ARDS）最佳通气策略很复杂，但在呼吸流行病期间，这对临床医生非常重要。比较小潮气量、大潮气量、高呼气末正压（PEEP）、俯卧位通气、高频振荡和静脉-静脉体外膜肺氧合（VV ECMO）对 ARDS 死亡率的影响。我们对随机试验进行了网络荟萃分析。我们应用推荐评估、制定和评估方法学（Grading of Recommendations Assessment, Development and Evaluation，GRADE）来辨别干预措施对死亡率的相对影响。我们分析了 34 项试验，共纳入 9085 例主要为中重度 ARDS 成人（中位基线 Pa/Fi 为 118；四分位间距为 110-143）。俯卧位通气联合小潮气量是最佳策略（风险比[RR]，0.74[95%置信区间（CI），0.60-0.92]与小潮气量；高确定性）。VV ECMO 也被评为最佳策略之一（RR，0.78[95% CI，0.58-1.05]与小潮气量；RR，0.66[95% CI，0.49-0.88]与大潮气量），但确定性较低，因为 VV ECMO 仅限于非常严重的 ARDS（中位基线 Pa/Fi<75）。高 PEEP 联合小潮气量被评为中度（RR，0.91[95% CI，0.81-1.03]与小潮气量；低确定性；RR，0.77[95% CI，0.65-0.91]与大潮气量；中确定性）。大潮气量被评为最差（RR，1.19[95% CI，1.02-1.37]与小潮气量；中确定性），并且我们没有发现高频振荡或俯卧位通气联合大潮气量的支持。这些发现表明，对于中重度 ARDS 危重症成人，小潮气量联合俯卧位通气与死亡率降低幅度最大相关。
