Recruitment manoeuvres for adults with acute respiratory distress syndrome receiving mechanical ventilation

Carol Hodgson; Ewan C Goligher; Meredith E Young; Jennifer L Keating; Anne E Holland; Lorena Romero; Scott J Bradley; David Tuxen

doi:10.1002/14651858.CD006667.pub3

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Figure 1

Study flow diagram.29

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Figure 2

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

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Figure 3

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

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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.

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Figure 5

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

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Analysis 1.1

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

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Analysis 1.2

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

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Analysis 1.3

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

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Analysis 1.4

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

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Analysis 1.5

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

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

Analysis 1.6

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

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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)	⊕⊕⊝⊝ Low^a	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)	⊕⊕⊝⊝ Low^a	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)	⊕⊕⊝⊝ Low^a	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)	⊕⊕⊕⊝ Moderate^b
	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.

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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.

Table 1. Description of recruitment manoeuvre procedure

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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	28‐day in hospital in ICU 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	28‐day in hospital in ICU	PaO₂/FiO₂	Barotrauma
Yang 2011	N/A	SpO₂ 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.

Table 2. Outcomes considered for this review

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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]

Comparison 1. Recruitment manoeuvres versus no recruitment manoeuvres

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