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Association between tidal volume and mortality in patients without acute respiratory distress syndrome: A systematic
Mingyuan Gu1, Feiping Xia1, Zhonghua Lu1
1Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu 210009, P.R. China.
Abstract:
The optimal tidal volume for mechanically ventilated patients without acute respiratory distress syndrome (ARDS) remains unclear. The present systematic review and meta-analysis compared the effects of low compared with high tidal volume (Vt) ventilation in non-ARDS patients. Randomized controlled trials and observational studies comparing low and high Vt in adults without ARDS were included. The primary outcome was short-term mortality (28- or 30-day mortality in the ICU or hospital). Secondary outcomes were days of ventilation, pulmonary complications and length of hospital stay. Summary odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model. In total, 18 studies were included (1,530 low Vt vs. 1,512 high Vt patients). No significant difference in short term mortality was observed between low and high Vt ventilation (n=12; OR, 0.88; 95% CI, 0.71-1.09; P=0.24). However, subgroup analysis by maximum airway pressure (Pmax) showed that low Vt with low Pmax significantly reduced short-term mortality compared with low Vt with Pmax (OR, 0.50; 95% CI, 0.34-0.75; P=0.0007). Low Vt also decreased days of ventilation [mean difference (MD), -1.00; 95% CI, -1.76--0.24; P=0.01], pulmonary complications (n=11 studies; OR, 0.40; 95% CI, 0.30-0.54; P<0.00001) and hospital stay (n=11 studies; MD, -1.49; 95% CI, -2.54--0.44; P=0.006). Trial sequential analysis indicated conclusive evidence, suggesting further trials are unlikely to change the conclusion. In conclusion, low Vt combined with low Pmax, but not low Vt alone, improved short-term mortality in non-ARDS patients with respiratory failure. Clinically, this suggests that limiting both tidal volume and airway pressure may offer a protective ventilation strategy for non-ARDS patients, potentially guiding bedside titration of ventilatory settings to reduce mortality. The present study was registered in PROSPERO (https://www.crd.york.ac.uk/PROSPERO/view/CRD42019119453).
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