Methods for determining optimal positive end-expiratory pressure in patients undergoing invasive mechanical ventilation: a scoping review.

IF 3.4 3区医学 Q1 ANESTHESIOLOGY Canadian Journal of Anesthesia-Journal Canadien D Anesthesie Pub Date : 2024-11-20 DOI:10.1007/s12630-024-02871-6

Stefan Edginton, Natalia Kruger, Henry T Stelfox, Laurent Brochard, Danny J Zuege, Jonathan Gaudet, Kevin Solverson, Helen Lee Robertson, Kirsten M Fiest, Daniel J Niven, Christopher J Doig, Sean M Bagshaw, Ken Kuljit S Parhar

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Abstract

Purpose: There is significant variability in the application of positive end-expiratory pressure (PEEP) in patients undergoing invasive mechanical ventilation. There are numerous studies assessing methods of determining optimal PEEP, but many methods, patient populations, and study settings lack high-quality evidence. Guidelines make no recommendations about the use of a specific method because of equipoise and lack of high-quality evidence. We conducted a scoping review to determine which methods of determining optimal PEEP have been studied and what gaps exist in the literature.

Source: We searched five databases for primary research reports studying methods of determining optimal PEEP among adults undergoing invasive mechanical ventilation. Data abstracted consisted of the titration method, setting, study design, population, and outcomes.

Principle findings: Two hundred and seventy-one studies with 17,205 patients met the inclusion criteria, including 73 randomized controlled trials (RCTs) with 10,733 patients. We identified 22 methods. Eleven were studied with an RCT. Studies enrolled participants within an intensive care unit (ICU) (216/271, 80%) or operating room (55/271, 20%). Most ICU studies enrolled patients with acute respiratory distress syndrome (162/216, 75%). The three most studied methods were compliance (73 studies, 29 RCTs), imaging-based methods (65 studies, 11 RCTs), and use of PEEP-F_IO₂ tables (52 studies, 20 RCTs). Among ICU RCTs, the most common primary outcomes were mortality or oxygenation. Few RCTs assessed feasibility of different methods (n = 3). The strengths and limitations of each method are discussed.

Conclusion: Numerous methods of determining optimal PEEP have been evaluated; however, notable gaps remain in the evidence supporting their use. These include specific populations (normal lungs, patients weaning from mechanical ventilation) and using alternate outcomes (ventilator-free days and feasibility) and they present significant opportunities for future study.

Study registration: Open Science Framework ( https://osf.io/atzqc ); first posted, 19 July 2022.

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有创机械通气患者最佳呼气末正压的确定方法：范围综述。

目的：在接受有创机械通气的患者中，呼气末正压 (PEEP) 的应用存在很大差异。有许多研究对确定最佳 PEEP 的方法进行了评估，但许多方法、患者人群和研究环境都缺乏高质量的证据。由于存在等效性和缺乏高质量证据，指南并未就特定方法的使用提出建议。我们进行了一次范围审查，以确定哪些确定最佳 PEEP 的方法已被研究过，以及文献中存在哪些空白：我们在五个数据库中检索了研究有创机械通气成人最佳 PEEP 确定方法的主要研究报告。摘录的数据包括滴定方法、环境、研究设计、人群和结果：有 17205 名患者参与的 271 项研究符合纳入标准，其中包括有 10733 名患者参与的 73 项随机对照试验 (RCT)。我们确定了 22 种方法。其中 11 项研究采用了随机对照试验。研究在重症监护室（ICU）（216/271，80%）或手术室（55/271，20%）内招募参与者。大多数重症监护室研究都招募了急性呼吸窘迫综合征患者（162/216，75%）。研究最多的三种方法是顺应性（73 项研究，29 项研究）、基于成像的方法（65 项研究，11 项研究）和使用 PEEP-FIO2 表（52 项研究，20 项研究）。在 ICU RCT 中，最常见的主要结果是死亡率或氧饱和度。很少有研究对不同方法的可行性进行评估（n = 3）。本文讨论了每种方法的优势和局限性：已对许多确定最佳 PEEP 的方法进行了评估；但是，支持使用这些方法的证据仍存在明显差距。这些差距包括特定人群（正常肺、机械通气断奶患者）和使用替代结果（无呼吸机天数和可行性），它们为未来研究提供了重要机会：开放科学框架 ( https://osf.io/atzqc ); 首次发布，2022 年 7 月 19 日。

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来源期刊

Canadian Journal of Anesthesia-Journal Canadien D Anesthesie 医学-麻醉学

CiteScore

8.50

自引率

7.10%

发文量

161

审稿时长

6-12 weeks

期刊介绍： The Canadian Journal of Anesthesia (the Journal) is owned by the Canadian Anesthesiologists’ Society and is published by Springer Science + Business Media, LLM (New York). From the first year of publication in 1954, the international exposure of the Journal has broadened considerably, with articles now received from over 50 countries. The Journal is published monthly, and has an impact Factor (mean journal citation frequency) of 2.127 (in 2012). Article types consist of invited editorials, reports of original investigations (clinical and basic sciences articles), case reports/case series, review articles, systematic reviews, accredited continuing professional development (CPD) modules, and Letters to the Editor. The editorial content, according to the mission statement, spans the fields of anesthesia, acute and chronic pain, perioperative medicine and critical care. In addition, the Journal publishes practice guidelines and standards articles relevant to clinicians. Articles are published either in English or in French, according to the language of submission.