Efficacy and Safety of Different Mechanical Ventilation Strategies for Patients with Acute Respiratory Distress Syndrome: Systematic Review and Network Meta-analysis

Abstract

Abstract Objective Acute respiratory distress syndrome (ARDS) leads to life-threatening acute hypoxemic respiratory failure and requires mechanical ventilation. However, there is a lack of certainty regarding recruitment maneuvers (RMs) and positive end-expiratory pressure (PEEP) levels. Therefore, we performed a network meta-analysis to identify the optimal RM and PEEP levels of patients with ARDS. Methods We searched the PubMed, OVID and Cochrane Central Register of Controlled Trials (Central) databases for randomized controlled trials (RCTs). The primary outcome was death on the 28th day, and the secondary outcomes included in-hospital death, ventilator-free days, and barotrauma. The relative effect sizes were estimated by risk ratios (RRs) for binary variables and standard mean difference (SMD) for continuous variables. The efficacy of the interventions was ranked using surface under the cumulative ranking. Multiple intervention comparisons based on the Bayesian framework were performed to integrate the efficacy of all included strategies. Results Thirteen RCTs comprising 4410 patients were included in the network meta-analysis. In terms of death at 28 days, inconsistencies were found globally and locally in the tests. None of the ventilation strategies was significantly superior to the others on any outcomes. According to the relative rank probabilities, RM + lower PEEP levels showed the highest probability of reducing the risk of in-hospital death and reducing ventilator-free days. Lower PEEP levels showed the highest probability of benefitting barotrauma. The overall quality of the evidence per grade was moderate to low. Conclusions The no ventilation strategy is significantly superior to the other strategies. RM + lower PEEP levels has the highest probability of benefitting survival. The evidence has low overall quality and should be further studied.