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This week's journal club is a SR/MA on APRV during acute hypoxaemic respiratory failure
ncbi.nlm.nih.gov/pubmed/30949778
ncbi.nlm.nih.gov/pubmed/30949778
Aim: A systematic review and meta-analysis to verify whether adult patients with hypoxemic respiratory failure had more ventilator-free days at day 28 when ventilated in APRV compared to conventional ventilation strategies.
Eligibility Criteria
RCTs only. Adults ≥ 18 diagnosed with acute hypoxamiec respiratory failure Pa02/Fi02 < 300mmHg) EXCLUDING those with severe chronic lung disease and or asthma.
RCTs only. Adults ≥ 18 diagnosed with acute hypoxamiec respiratory failure Pa02/Fi02 < 300mmHg) EXCLUDING those with severe chronic lung disease and or asthma.
Intervention & comparator
APRV compared to any type of conventional ventilation
APRV compared to any type of conventional ventilation
Outcomes
Primary: Ventilator-free days at day 28.
Secondary: Differences in oxygenation (Pa02/Fi02 at day 3), ICU LOS, ICU and
hospital mortality, mean arterial pressure, risk of barotrauma and level of sedation
Primary: Ventilator-free days at day 28.
Secondary: Differences in oxygenation (Pa02/Fi02 at day 3), ICU LOS, ICU and
hospital mortality, mean arterial pressure, risk of barotrauma and level of sedation
Results
306 papers identified for screening. 5 RCTs analysed after exclusions. A total of 330 patients (largest trial 138 patients, smallest trial 30 patients). All published between 2001-2018. All single centred trials.
306 papers identified for screening. 5 RCTs analysed after exclusions. A total of 330 patients (largest trial 138 patients, smallest trial 30 patients). All published between 2001-2018. All single centred trials.
Compared with conventional ventilation the APRV groups showed:
1. higher ventilatory-free days at day 28
2. shorter ICU LOS
3. decreased hospital mortality
4. higher MAP
1. higher ventilatory-free days at day 28
2. shorter ICU LOS
3. decreased hospital mortality
4. higher MAP
No difference between groups with regard to Pa02/Fi02 at day 3 or onset of pneumothorax. ICU mortality and sedation level were not included into analysis.
Strengths
First systematic review and meta-analysis investigating APRV vs conventional ventilation in adults with acute hypoxaemic respiratory failure.
First systematic review and meta-analysis investigating APRV vs conventional ventilation in adults with acute hypoxaemic respiratory failure.
Weaknesses
1. Low study number & all single centred trials.
2. Low study quality - heterogeneity in methodology (patient selection, Pa02/Fi02 stratification, timing of commencing APRV), lack of blinding, high risk of bias
3. 2 studies from prior to ARMA trial (permitted high TV)
1. Low study number & all single centred trials.
2. Low study quality - heterogeneity in methodology (patient selection, Pa02/Fi02 stratification, timing of commencing APRV), lack of blinding, high risk of bias
3. 2 studies from prior to ARMA trial (permitted high TV)
Final thoughts
Interesting glance at the literature. There are possibly more questions raised than answers provided. At present unlikely to change current practice. A well designed multi centre RCT is needed to provide further insight into this topic.
Interesting glance at the literature. There are possibly more questions raised than answers provided. At present unlikely to change current practice. A well designed multi centre RCT is needed to provide further insight into this topic.
Questions raised:
1. Utility of spontaneous breathing with APRV in patients with severe ARDS when current literature suggests lower mortality with early short term neuromuscular blockade.
2. Variability in initial APRV settings, is there a proven method or are we guessing?
1. Utility of spontaneous breathing with APRV in patients with severe ARDS when current literature suggests lower mortality with early short term neuromuscular blockade.
2. Variability in initial APRV settings, is there a proven method or are we guessing?
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