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Study flow diagram.29
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Figure 1

Study flow diagram.29

Forest plot of comparison: 1 Recruitment manoeuvres versus no recruitment manoeuvres, outcome: 1.1 28‐Day mortality.
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Figure 2

Forest plot of comparison: 1 Recruitment manoeuvres versus no recruitment manoeuvres, outcome: 1.1 28‐Day mortality.

Forest plot of comparison: 1 Recruitment manoeuvres versus no recruitment manoeuvres, outcome: 1.7 ICU mortality.
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Figure 3

Forest plot of comparison: 1 Recruitment manoeuvres versus no recruitment manoeuvres, outcome: 1.7 ICU mortality.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 4

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 5

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 Recruitment manoeuvres versus no recruitment manoeuvres, Outcome 1 28‐Day mortality.
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Analysis 1.1

Comparison 1 Recruitment manoeuvres versus no recruitment manoeuvres, Outcome 1 28‐Day mortality.

Comparison 1 Recruitment manoeuvres versus no recruitment manoeuvres, Outcome 2 ICU mortality.
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Analysis 1.2

Comparison 1 Recruitment manoeuvres versus no recruitment manoeuvres, Outcome 2 ICU mortality.

Comparison 1 Recruitment manoeuvres versus no recruitment manoeuvres, Outcome 3 In‐hospital mortality.
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Analysis 1.3

Comparison 1 Recruitment manoeuvres versus no recruitment manoeuvres, Outcome 3 In‐hospital mortality.

Comparison 1 Recruitment manoeuvres versus no recruitment manoeuvres, Outcome 4 Rate of barotrauma.
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Analysis 1.4

Comparison 1 Recruitment manoeuvres versus no recruitment manoeuvres, Outcome 4 Rate of barotrauma.

Comparison 1 Recruitment manoeuvres versus no recruitment manoeuvres, Outcome 5 Use of rescue therapies.
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Analysis 1.5

Comparison 1 Recruitment manoeuvres versus no recruitment manoeuvres, Outcome 5 Use of rescue therapies.

Comparison 1 Recruitment manoeuvres versus no recruitment manoeuvres, Outcome 6 PaO2/FiO2 ratio at 24 to 48 hours.
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Analysis 1.6

Comparison 1 Recruitment manoeuvres versus no recruitment manoeuvres, Outcome 6 PaO2/FiO2 ratio at 24 to 48 hours.

Recruitment manoeuvres compared with standard care for adults with acute respiratory distress syndrome who were mechanically ventilated

Patient or population: mechanically ventilated adults with acute respiratory distress syndrome. Participants were recruited from ICUs internationally, including Australia, Brazil, China, Europe, Canada, Korea, Seoul, Taiwan and the United States.

Settings: intensive care unit

Intervention: recruitment manoeuvres

Comparison: standard care

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Intervention

28‐Day mortality

Risk for the population

RR 0.86 (0.74 to 1.01)

1450
(5 studies)

⊕⊕⊝⊝
Lowa

Four of the 5 trials include co‐interventions that may influence the result of the outcome.

347 per 1000

294 per 1000

ICU mortality

Risk for the population

RR 0.83 (0.72 to 0.97)

1370
(5 studies)

⊕⊕⊝⊝
Lowa

Four of the 5 trials include co‐interventions that may influence the result of the outcome.

362 per 1000

303 per 1000

In‐hospital mortality

Risk for the population

RR 0.88 (0.77 to 1.01)

1313
(4 studies)

⊕⊕⊝⊝
Lowa

Three of the 4 trials include co‐interventions that may influence the result of the outcome.

405 per 1000

356 per 1000

Rate of barotrauma

Risk for the population

RR 1.09 (0.78 to 1.51)

1508
(7 studies)

⊕⊕⊕⊝
Moderateb

90 per 1000

86 per 1000

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aLung recruitment manoeuvres were used with co‐interventions that may affect the result of the outcome (Hodgson 2011; Meade 2008; Huh 2009; Kacmarek 2016; Liu 2011). We downgraded the quality of the evidence by two levels for indirectness of evidence. We made this decision a priori.

bWe noted no heterogeneity among trial effect estimates but observed that reported confidence intervals around effect estimates were wide. We downgraded the quality of the evidence by one level for imprecision in results.

Figures and Tables -
Table 1. Description of recruitment manoeuvre procedure

Study

Mode

Peak pressure

(cm H2O)

Time

(sec)

PEEP titration differed between groups

Mean PEEP after RM

(cm H2O)

Repetitions

Cavalcanti et al, 2013

PCV

60 (delivered incrementally)

240

Yes

16.1

Daily (+ after desaturation or disconnection)

Hodgson 2011

PCV

55 (delivered incrementally)

360

Yes

17.4

Daily (+ after desaturation or disconnection)

Huh 2009

VCV

≤ 55 (delivered incrementally to 25 cm H2O PEEP with decremental tidal volume setting)

NS

Yes

10

Daily (+ after desaturation or disconnection)

Kacmarek 2016

PCV

≤ 60 depending on the participant's response (delivered incrementally to PEEP 35 to 45 cm H2O)

120

Yes

15.8

NS

Liu 2011

NS

NS

NS

Yes

NS

NS

Meade 2008

PCV

40

40

Yes

14.6

Frequently after disconnection

Oczenski 2004

PCV

50

30

No

15.1

Once

Wang 2009

BIPAP

NS

NS

N/A

NS

Eight‐hourly

Xi 2010

CPAP

40 (cm H2O CPAP)

40

No

10.5

Eight‐hourly

Yang 2011

CPAP

40 (cm H2O CPAP)

30

No

NS

Eight‐hourly

Huh 2009 ‐ RM with incremental and decremental titration cycled twice over 10 minutes.

BIPAP = bi‐level positive airway pressure; CPAP = continuous positive airway pressure; NS = not stated; PCV = pressure‐cycled ventilation; sec = seconds; VCV = volume‐cycled ventilation.

Figures and Tables -
Table 1. Description of recruitment manoeuvre procedure
Table 2. Outcomes considered for this review

Study

Mortality

Oxygenation

Adverse events

Cavalcanti et al, 2013

N/A

PaO2/FiO2

Barotrauma

Hodgson 2011

1. in hospital

PaO2/FiO2

Barotrauma

Rescue therapies

Huh 2009

1. 28‐day

2. in ICU

PaO2/FiO2

Barotrauma

Rescue therapies

Kacmarek 2016

1. in hospital

2. in ICU

Barotrauma

Liu 2011

28‐day

PaO2/FiO2

Barotrauma

Meade 2008

  1. 28‐day

  2. in hospital

  3. in ICU

  4. during mechanical ventilation

PaO2/FiO2

Barotrauma

Rescue therapies

Oczenski 2004

N/A

PaO2/FiO2

N/A

Wang 2009

N/A

PaO2/FiO2

N/A

Xi 2010

  1. 28‐day

  2. in hospital

  3. in ICU

PaO2/FiO2

Barotrauma

Yang 2011

N/A

  1. SpO2

  2. PaO2/FiO2

Barotrauma

Pneumonia

CO = cardiac output; FiO2/PEEP step = changes in level of inspired oxygen at set levels of positive end‐expiratory pressure; HR = heart rate; ICU = intensive care unit; MAP = mean arterial pressure; N/A = not available; PaO2/FiO2 = fraction of arterial oxygen to inspired oxygen; SBP = systolic blood pressure; SpO2 = oxygen saturation from pulse oximetry.

Figures and Tables -
Table 2. Outcomes considered for this review
Comparison 1. Recruitment manoeuvres versus no recruitment manoeuvres

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 28‐Day mortality Show forest plot

5

1450

Risk Ratio (M‐H, Fixed, 95% CI)

0.86 [0.74, 1.01]

1.1 Open lung ventilation including recruitment manoeuvres

4

1340

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.75, 1.04]

1.2 Recruitment manoeuvres

1

110

Risk Ratio (M‐H, Fixed, 95% CI)

0.67 [0.40, 1.11]

2 ICU mortality Show forest plot

5

1370

Risk Ratio (M‐H, Fixed, 95% CI)

0.85 [0.73, 0.99]

2.1 Open lung ventilation including recruitment manoeuvres

4

1260

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.75, 1.03]

2.2 Recruitment manoeuvres

1

110

Risk Ratio (M‐H, Fixed, 95% CI)

0.62 [0.39, 0.98]

3 In‐hospital mortality Show forest plot

4

1313

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.77, 1.01]

3.1 Open lung ventilation including recruitment manoeuvres

3

1203

Risk Ratio (M‐H, Fixed, 95% CI)

0.90 [0.78, 1.04]

3.2 Recruitment manoeuvres

1

110

Risk Ratio (M‐H, Fixed, 95% CI)

0.74 [0.50, 1.09]

4 Rate of barotrauma Show forest plot

7

1508

Risk Ratio (M‐H, Fixed, 95% CI)

1.09 [0.78, 1.51]

4.1 Open lung ventilation including recruitment manoeuvres

6

1398

Risk Ratio (M‐H, Fixed, 95% CI)

1.09 [0.78, 1.51]

4.2 Recruitment manoeuvres

1

110

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

5 Use of rescue therapies Show forest plot

3

1060

Risk Ratio (M‐H, Random, 95% CI)

0.64 [0.27, 1.51]

6 PaO2/FiO2 ratio at 24 to 48 hours Show forest plot

6

1270

Mean Difference (IV, Random, 95% CI)

‐39.10 [‐57.64, ‐20.56]

6.1 Open lung ventilation including recruitment manoeuvres

5

1160

Mean Difference (IV, Random, 95% CI)

‐44.76 [‐66.29, ‐23.22]

6.2 Recruitment manoeuvres

1

110

Mean Difference (IV, Random, 95% CI)

‐17.0 [‐37.19, 3.19]

Figures and Tables -
Comparison 1. Recruitment manoeuvres versus no recruitment manoeuvres