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2014 ; 40
(6
): 769-87
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Effects of interventions on survival in acute respiratory distress syndrome: an
umbrella review of 159 published randomized trials and 29 meta-analyses
#MMPMID24667919
Tonelli AR
; Zein J
; Adams J
; Ioannidis JP
Intensive Care Med
2014[Jun]; 40
(6
): 769-87
PMID24667919
show ga
PURPOSE: Multiple interventions have been tested in acute respiratory distress
syndrome (ARDS). We examined the entire agenda of published randomized controlled
trials (RCTs) in ARDS that reported on mortality and of respective meta-analyses.
METHODS: We searched PubMed, the Cochrane Library, and Web of Knowledge until
July 2013. We included RCTs in ARDS published in English. We excluded trials of
newborns and children; and those on short-term interventions, ARDS prevention, or
post-traumatic lung injury. We also reviewed all meta-analyses of RCTs in this
field that addressed mortality. Treatment modalities were grouped in five
categories: mechanical ventilation strategies and respiratory care, enteral or
parenteral therapies, inhaled/intratracheal medications, nutritional support, and
hemodynamic monitoring. RESULTS: We identified 159 published RCTs of which 93 had
overall mortality reported (n = 20,671 patients)--44 trials (14,426 patients)
reported mortality as a primary outcome. A statistically significant survival
benefit was observed in eight trials (seven interventions) and two trials
reported an adverse effect on survival. Among RCTs with more than 50 deaths in at
least one treatment arm (n = 21), two showed a statistically significant
mortality benefit of the intervention (lower tidal volumes and prone
positioning), one showed a statistically significant mortality benefit only in
adjusted analyses (cisatracurium), and one (high-frequency oscillatory
ventilation) showed a significant detrimental effect. Across 29 meta-analyses,
the most consistent evidence was seen for low tidal volumes and prone positioning
in severe ARDS. CONCLUSIONS: There is limited supportive evidence that specific
interventions can decrease mortality in ARDS. While low tidal volumes and prone
positioning in severe ARDS seem effective, most sporadic findings of
interventions suggesting reduced mortality are not corroborated consistently in
large-scale evidence including meta-analyses.