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Comparison of ventilatory modes to facilitate liberation from mechanical ventilation: protocol for a systematic review and network meta-analysis.

ABSTRACT: INTRODUCTION:Timely liberation from invasive mechanical ventilation is important to reduce the risk of ventilator-associated complications. Once a patient is deemed ready to tolerate a mode of partial ventilator assist, clinicians can use one of multiple ventilatory modes. Despite multiple trials, controversy regarding the optimal ventilator mode to facilitate liberation remains. Herein, we report the protocol for a systematic review and network meta-analysis comparing modes of ventilation to facilitate the liberation of a patient from invasive mechanical ventilation. METHODS AND ANALYSIS:We will search MEDLINE, EMBASE, PubMed, the Cochrane Library from inception to April 2019 for randomised trials that report on critically ill adults who have undergone invasive mechanical ventilation for at least 24 hours and have received any mode of assisted invasive mechanical ventilation compared with an alternative mode of assisted ventilation. Outcomes of interest will include: mortality, weaning success, weaning duration, duration of mechanical ventilation, duration of stay in the acute care setting and adverse events. Two reviewers will independently screen in two stages, first titles and abstracts, and then full texts, to identify eligible studies. Independently and in duplicate, two investigators will extract all data, and assess risk of bias in all eligible studies using the Modified Cochrane Risk of Bias tool. Reviewers will resolve disagreement by discussion and consultation with a third reviewer as necessary. Using a frequentist framework, we will perform random-effect network meta-analysis, including all ventilator modes in the same model. We will calculate direct and indirect estimates of treatment effect using a node-splitting procedure and report effect estimates using OR and 95% CI. We will assess certainty in effect estimates using Grading of Recommendations Assessment, Development and Evaluation methodology. ETHICS AND DISSEMINATION:Research ethics board approval is not necessary. The results will be disseminated through publication in a peer-reviewed journals. PROSPERO REGISTRATION NUMBER:CRD42019137786.

SUBMITTER: Lewis KA

PROVIDER: S-EPMC6731837 | biostudies-other | 2019 Sep

REPOSITORIES: biostudies-other

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Comparison of ventilatory modes to facilitate liberation from mechanical ventilation: protocol for a systematic review and network meta-analysis.

Lewis Kimberley A KA Chaudhuri Dipayan D Guyatt Gordon G Burns Karen E A KEA Bosma Karen K Ge Long L Karachi Tim T Piraino Thomas T Fernando Shannon M SM Ranganath Nischal N Brochard Laurent L Rochwerg Bram B

BMJ open 20190905 9

<h4>Introduction</h4>Timely liberation from invasive mechanical ventilation is important to reduce the risk of ventilator-associated complications. Once a patient is deemed ready to tolerate a mode of partial ventilator assist, clinicians can use one of multiple ventilatory modes. Despite multiple trials, controversy regarding the optimal ventilator mode to facilitate liberation remains. Herein, we report the protocol for a systematic review and network meta-analysis comparing modes of ventilati ...[more]

PMID: 31492786

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Project description:IntroductionPredicting successful liberation from mechanical ventilation (MV) among critically ill patients receiving MV can be challenging. The current parameters used to predict successful extubation have shown variable predictive value. Brain natriuretic peptide (BNP) has been proposed as a novel biomarker to help guide decision-making in readiness for liberation of MV following a spontaneous breathing trial (SBT). Current evidence on the predictive ability of BNP has been uncertain, and BNP has not been integrated into clinical practice guidelines.Methods and analysisWe will perform a systematic review and meta-analysis to evaluate the value of BNP during SBT to predict success of liberation from MV. A search strategy will be developed in collaboration with a research librarian, and electronic databases (MEDLINE, EMBASE, Cochrane Library, Web of Science) and additional sources will be searched. Search themes will include: (1) BNP and (2) weaning, extubation and/or liberation from MV. Citation screening, selection, quality assessment and data abstraction will be performed in duplicate. The primary outcome will be liberation from MV; secondary outcomes will include time to reintubation, mortality, MV duration, total and postextubation intensive care unit (ICU) stay, hospitalisation duration, tracheostomy rate, ICU-acquired weakness rate and ventilator-free days. Primary statistical analysis will include predictive value of BNP by receiver operating characteristic curve, sensitivity/specificity and likelihood ratios for combination of BNP and SBT parameters for failure of liberation from MV. Secondary statistical analysis will be performed on individual and combinations of extracted metrics.Ethics and disseminationOur review will add knowledge by mapping the current body of evidence on the value of BNP testing for prediction of successful liberation from MV, and describe knowledge gaps and research priorities. Our findings will be disseminated through peer-reviewed publication, presentation at a scientific congress, through regional/national organisations and social media. Research ethics approval is not required.Prospero registration numberCRD42018087474.

Project description:BackgroundEndotheliopathy is suggested as pivotal pathophysiology of sepsis and trauma-associated organ failure, but its role in acute respiratory failure is not yet determined. We investigated if endotheliopathy biomarkers at ICU admission are associated with illness severity and clinical outcomes in patients with acute respiratory failure requiring mechanical ventilation.MethodsWe conducted a prospective single-center cohort study including 459 mechanically ventilated adults at ICU admission. Plasma levels of three endotheliopathy biomarkers were measured at ICU admission: Syndecan-1, soluble Thrombomodulin (sTM), and Platelet Endothelial Cell Adhesion Molecule-1 (PECAM-1). The primary outcome was the rate of liberation from mechanical ventilation, which is presented together with the rate of the competing risk of death while still on mechanical ventilation. Secondary outcomes were PaO2/FiO2-ratios on admission and on last measurement in patients dying within five days, and 30-day all-cause mortality. The primary outcome and 30-day all-cause mortality were analyzed using Cox regression, controlled for gender, age, chronic obstructive pulmonary disease, septic shock, heart failure, PaO2/FiO2-ratio at admission, respiratory infection, acute kidney injury, and bilirubin. PaO2/FiO2-ratios were analyzed using linear regression, controlled for age, chronic obstructive pulmonary disease, respiratory infection, and shock.ResultsPatients with high sTM were liberated from mechanical ventilation at a lower rate (adjusted hazard ratio (HR) 0.71, for an increase from the 25th to the 75th percentile, 95% confidence interval (CI) 0.54-0.93, p = 0.01). Patients with high PECAM-1 were liberated from mechanical ventilation at a lower rate, but only during the first 5 days (adjusted HR 0.72, for an increase from the 25th to the 75th percentile, 95% CI 0.58-0.9, p < 0.01). High levels of Syndecan-1 and PECAM-1 were associated with a higher rate of death while still on mechanical ventilation. sTM and PECAM-1 were negatively associated with PaO2/FiO2-ratio at ICU admission and no biomarker was associated with last measured PaO2/FiO2-ratio. High levels of all biomarkers were associated with higher 30-day all-cause mortality.ConclusionIn acute respiratory failure, endotheliopathy biomarkers are associated with lower rates of liberation from mechanical ventilation, hypoxemia at ICU admission, and 30-day all-cause mortality.

Project description:ObjectivesTo map the evidence for ventilation liberation practices in pediatric respiratory failure using the Realist And MEta-narrative Evidence Syntheses: Evolving Standards publication standards.Data sourcesCINAHL, MEDLINE, COCHRANE, and EMBASE. Trial registers included the following: ClinicalTrials.gov, European Union clinical trials register, International Standardized Randomized Controlled Trial Number register.Study selectionAbstracts were screened followed by review of full text. Articles published in English language incorporating a heterogeneous population of both infants and older children were assessed.Data extractionNone.Data synthesisWeaning can be considered as the process by which positive pressure is decreased and the patient becomes increasingly responsible for generating the energy necessary for effective gas exchange. With the growing use of noninvasive respiratory support, extubation can lie in the middle of the weaning process if some additional positive pressure is used after extubation, while for some extubation may constitute the end of weaning. Testing for extubation readiness is a key component of the weaning process as it allows the critical care practitioner to assess the capability and endurance of the patient's respiratory system to resume unassisted ventilation. Spontaneous breathing trials (SBTs) are often seen as extubation readiness testing (ERT), but the SBT is used to determine if the patient can maintain adequate spontaneous ventilation with minimal ventilatory support, whereas ERT implies the patient is ready for extubation.ConclusionsCurrent literature suggests using a structured approach that includes a daily assessment of patient's readiness to extubate may reduce total ventilation time. Increasing evidence indicates that such daily assessments needs to include SBTs without added pressure support. Measures of elevated load as well as measures of impaired respiratory muscle capacity are independently associated with extubation failure in children, indicating that these should also be assessed as part of ERT.

Project description:IntroductionThe purpose of the present study was to critically review the existing body of evidence on ventilation modes for infants and children up to the age of 18 years.MethodsThe PubMed and EMBASE databases were searched using the search terms 'artificial respiration', 'instrumentation', 'device', 'devices', 'mode', and 'modes'. The review included only studies comparing two ventilation modes in a randomized controlled study and reporting one of the following outcome measures: length of ventilation (LOV), oxygenation, mortality, chronic lung disease and weaning. We quantitatively pooled the results of trials where suitable.ResultsFive trials met the inclusion criteria. They addressed six different ventilation modes in 421 children: high-frequency oscillation (HFO), pressure control (PC), pressure support (PS), volume support (VS), volume diffusive respirator (VDR) and biphasic positive airway pressure. Overall there were no significant differences in LOV and mortality or survival rate associated with the different ventilation modes. Two trials compared HFO versus conventional ventilation. In the pooled analysis, the mortality rate did not differ between these modes (odds ratio = 0.83, 95% confidence interval = 0.30 to 1.91). High-frequency ventilation (HFO and VDR) was associated with a better oxygenation after 72 hours than was conventional ventilation. One study found a significantly higher PaO2/FiO2 ratio with the use of VDR versus PC ventilation in children with burns. Weaning was studied in 182 children assigned to either a PS protocol, a VS protocol or no protocol. Most children could be weaned within 2 days and the weaning time did not significantly differ between the groups.ConclusionsThe literature provides scarce data for the best ventilation mode in critically ill children beyond the newborn period. There is no evidence, however, that high-frequency ventilation reduced mortality and LOV. Longer-term outcome measures such as pulmonary function, neurocognitive development, and cost-effectiveness should be considered in future studies.

Project description:BACKGROUND:Volume-controlled ventilation has been suggested to optimize lung deposition during nebulization although promoting spontaneous ventilation is targeted to avoid ventilator-induced diaphragmatic dysfunction. Comparing topographic aerosol lung deposition during volume-controlled ventilation and spontaneous ventilation in pressure support has never been performed. The aim of this study was to compare lung deposition of a radiolabeled aerosol generated with a vibrating-mesh nebulizer during invasive mechanical ventilation, with two modes: pressure support ventilation and volume-controlled ventilation. METHODS:Seventeen postoperative neurosurgery patients without pulmonary disease were randomly ventilated in pressure support or volume-controlled ventilation. Diethylenetriaminepentaacetic acid labeled with technetium-99m (2 mCi/3 mL) was administrated using a vibrating-mesh nebulizer (Aerogen Solo(®), provided by Aerogen Ltd, Galway, Ireland) connected to the endotracheal tube. Pulmonary and extrapulmonary particles deposition was analyzed using planar scintigraphy. RESULTS:Lung deposition was 10.5 ± 3.0 and 15.1 ± 5.0 % of the nominal dose during pressure support and volume-controlled ventilation, respectively (p < 0.05). Higher endotracheal tube and tracheal deposition was observed during pressure support ventilation (27.4 ± 6.6 vs. 20.7 ± 6.0 %, p < 0.05). A similar penetration index was observed for the right (p = 0.210) and the left lung (p = 0.211) with both ventilation modes. A high intersubject variability of lung deposition was observed with both modes regarding lung doses, aerosol penetration and distribution between the right and the left lung. CONCLUSIONS:In the specific conditions of the study, volume-controlled ventilation was associated with higher lung deposition of nebulized particles as compared to pressure support ventilation. The clinical benefit of this effect warrants further studies. Clinical trial registration NCT01879488.

Project description:BACKGROUND:Proportional modes (proportional assist ventilation, PAV, and neurally adjusted ventilatory assist, NAVA) could improve patient-ventilator interaction and consequently may be efficient as a weaning mode. The purpose of this systematic review is to examine whether proportional modes improved patient-ventilator interaction and whether they had an impact on the weaning success and length of mechanical ventilation, in comparison with PSV. METHODS:We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception through May 13, 2018. We included both parallel-group and crossover randomized studies that examined the efficacy of proportional modes in comparison with PSV in mechanically ventilated adults. The primary outcomes were (1) asynchrony index (AI), (2) weaning failure, and (3) duration of mechanical ventilation. RESULTS:We included 15 studies (four evaluated PAV, ten evaluated NAVA, and one evaluated both modes). Although the use of proportional modes was not associated with a reduction in AI (WMD -?1.43; 95% CI -?3.11 to 0.25; p?=?0.096; PAV-one study, and NAVA-seven studies), the use of proportional modes was associated with a reduction in patients with AI?>?10% (RR 0.15; 95% CI 0.04-0.58; p?=?0.006; PAV-two studies, and NAVA-five studies), compared with PSV. There was a significant heterogeneity among studies for AI, especially with NAVA. Compared with PSV, use of proportional modes was associated with a reduction in weaning failure (RR 0.44; 95% CI 0.26-0.75; p?=?0.003; PAV-three studies) and duration of mechanical ventilation (WMD -?1.78 days; 95% CI -?3.24 to -?0.32; p?=?0.017; PAV-three studies, and NAVA-two studies). Reduced duration of mechanical ventilation was found with PAV but not with NAVA. CONCLUSION:The use of proportional modes was associated with a reduction in the incidence with AI?>?10%, weaning failure and duration of mechanical ventilation, compared with PSV. However, reduced weaning failure and duration of mechanical ventilation were found with only PAV. Due to a significant heterogeneity among studies and an insufficient number of studies, further investigation seems warranted to better understand the impact of proportional modes. Clinical trial registration PROSPERO registration number, CRD42017059791. Registered 20 March 2017.

Project description:To determine whether benzodiazepine and propofol doses are increased at night and whether daytime and nighttime sedative doses are associated with delirium, coma, and delayed liberation from mechanical ventilation.Single-center, prospective cohort study nested within the Awakening and Breathing Controlled randomized trial.Saint Thomas Hospital in Nashville, TN, from 2004 to 2006.Adult patients receiving mechanical ventilation for >12 hrs with continuous recording of hourly sedation dosing.We measured hourly doses of benzodiazepine and propofol exposure during the daytime (7 AM to 11 PM) and nighttime (11 PM to 7 AM) for 5 days. We quantified nighttime dose increases by subtracting the average hourly daytime dose on the preceding day from subsequent average hourly nighttime dose. We used multivariable logistic regression to determine whether daytime and nighttime dose increases were independently associated with delirium, coma, and delayed liberation from mechanical ventilation.Among 140 patients, the median Acute Physiology and Chronic Health Evaluation II score was 27 (interquartile range 22-33). Among those receiving the sedatives, benzodiazepine and propofol doses were increased at night on 40% and 41% of patient-days, respectively. Of 485 patient-days, delirium was present on 160 (33%) and coma on 206 (42%). In adjusted models, greater daytime benzodiazepine dose was independently associated with failed spontaneous breathing trial and extubation, and subsequent delirium (p<.02 for all). Nighttime increase in benzodiazepine dose was associated with failed spontaneous breathing trial (p<.01) and delirium (p=.05). Daytime propofol dose was marginally associated with subsequent delirium (p=.06).Nearly half of mechanically ventilated intensive care unit patients received greater doses of sedation at night, a practice associated with failed spontaneous breathing trials, coma, and delirium. Over the first 5 days in our study, patients spent 75% of their time in coma or delirium, outcomes that may be reduced by efforts to decrease sedative exposure during both daytime and nighttime hours in the intensive care unit.

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Comparison of ventilatory modes to facilitate liberation from mechanical ventilation: protocol for a systematic review and network meta-analysis.

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Comparison of ventilatory modes to facilitate liberation from mechanical ventilation: protocol for a systematic review and network meta-analysis.

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