Inconsistent Methods Used to Set Airway Pressure Release Ventilation in Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Regression Analysis

Author:

Lutz Mark R.1,Charlamb Jacob1,Kenna Joshua R.1,Smith Abigail2ORCID,Glatt Stephen J.345,Araos Joaquin D.6,Andrews Penny L.7,Habashi Nader M.7,Nieman Gary F.1ORCID,Ghosh Auyon J.8ORCID

Affiliation:

1. Department of Surgery, SUNY Upstate Medical University, Syracuse, NY 13210, USA

2. Health Sciences Library, SUNY Upstate Medical University, Syracuse, NY 13210, USA

3. Department of Psychiatry and Behavioral Sciences, SUNY Upstate Medical University, Syracuse, NY 13210, USA

4. Department of Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, NY 13210, USA

5. Department of Public Health and Preventive Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, USA

6. Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA

7. Department of Critical Care, R Adams Cowley Shock Trauma Center, Baltimore, MD 21201, USA

8. Division of Pulmonary, Critical Care, and Sleep Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, USA

Abstract

Airway pressure release ventilation (APRV) is a protective mechanical ventilation mode for patients with acute respiratory distress syndrome (ARDS) that theoretically may reduce ventilator-induced lung injury (VILI) and ARDS-related mortality. However, there is no standard method to set and adjust the APRV mode shown to be optimal. Therefore, we performed a meta-regression analysis to evaluate how the four individual APRV settings impacted the outcome in these patients. Methods: Studies investigating the use of the APRV mode for ARDS patients were searched from electronic databases. We tested individual settings, including (1) high airway pressure (PHigh); (2) low airway pressure (PLow); (3) time at high airway pressure (THigh); and (4) time at low pressure (TLow) for association with PaO2/FiO2 ratio and ICU length of stay. Results: There was no significant difference in PaO2/FiO2 ratio between the groups in any of the four settings (PHigh difference −12.0 [95% CI −100.4, 86.4]; PLow difference 54.3 [95% CI −52.6, 161.1]; TLow difference −27.19 [95% CI −127.0, 72.6]; THigh difference −51.4 [95% CI −170.3, 67.5]). There was high heterogeneity across all parameters (PhHgh I2 = 99.46%, PLow I2 = 99.16%, TLow I2 = 99.31%, THigh I2 = 99.29%). Conclusions: None of the four individual APRV settings independently were associated with differences in outcome. A holistic approach, analyzing all settings in combination, may improve APRV efficacy since it is known that small differences in ventilator settings can significantly alter mortality. Future clinical trials should set and adjust APRV based on the best current scientific evidence available.

Funder

U.S. National Institutes of Health

U.S. Department of Defense

Publisher

MDPI AG

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