Development of ARDS as an outcome was reported in 14 ICU studies, while the occurrence of postoperative pulmonary complications was reported in 7 OR studies. Reported incidences of ARDS and postoperative pulmonary complications varied between studies (Supplemental Digital Content 2, Figures 9–10, http://links.lww.com/AA/C555). Due to the limited number of studies and the short time frame these studies cover, statistical assessment of associations between temporal changes in VT size and incidences of ARDS development or postoperative pulmonary complications was not conducted.
In this systematic review of 192 studies and >120,000 patients with uninjured lungs, we found that prescribed VTs during clinical studies of mechanical ventilation decreased in both ICU and OR during the period from 1975 to 2014.
Our main findings are consistent with 3 reports from 2015 investigating the development of intraoperative ventilation patterns in single or a small number of centers over time.217–219 All found a decrease in VT size during the last 7–20 years. Furthermore, in contrast to our data, in 2 of these studies,217,219 the proportion of patients in whom PEEP was applied has increased significantly since 2005219 and 2008.217 Despite theoretically beneficial effects, large investigations have so far failed to prove any positive effect on patient outcome when groups were only randomized to different PEEP values in patients experiencing ARDS220 or in surgical patients,115 which may explain the large heterogeneity in PEEP levels in our review.
We did not find a temporal change in clinical outcomes, which were the development of ARDS in the ICU and incidences of postoperative pulmonary complications in the OR. Incidences of pulmonary injury varied widely in the analyzed studies, suggesting either heterogeneity of study populations or incomplete or imprecise reporting of pulmonary complications in some observational and retrospective studies. Of note, 11 ICU studies35–37,45,58,61,63,67,73,88,114 and 11 OR studies117,142,144,146,147,158,161,178,188,192,201 reported a VT size of ≤7 mL/kg (Figures 2–3). In a recent meta-analysis of individual patient data, VTs of 7 mL/kg PBW or less, but not 7–10 mL/kg PBW, reduced pulmonary complications in ICU patients without ARDS.7 Thus, the lack of studies with such low VT might be another reason for the lack of changes in the development of ARDS and postoperative pulmonary complications.
Our approach has some strengths. First, our nonrestrictive search strategy maximized the number of included investigations. Consequently, the analysis reflects ventilation practice in a large number of cohorts of patients worldwide over a long period of time. Second, rather than reporting original data from individual institutions,218,219 we chose to analyze temporal change of reported VT in published literature. We preferred this approach because ventilation practice might differ significantly between individual institutions.217 Consequently, observations at single centers, or even in individual countries, might substantially differ from general practice patterns. We therefore believe that our approach might give a better estimate of general ventilation patterns than single-center or single-country studies.
Our analysis also exhibits some limitations. Only including publications reporting VT sizes may have caused some bias because investigators who report on this ventilation setting may be more aware of the potential benefit of VT reduction in patients without ARDS. Furthermore, several trials added >1 cohort to our analysis. Thus, there is a small fraction of data points that are not independent from each other. We decided against extracting and analyzing data on mode of ventilation (ie, volume-controlled versus pressure-controlled ventilation) because modes of ventilation were often mixed and not clearly distinguishable making an appropriate analysis unfeasible. We included groups from randomized controlled trials in our primary analysis that were defined to reflect ventilation practice at the time the study was conducted. In turn, we had to exclude from our primary analysis any randomized controlled trials in which no group was defined as reflecting the standard of care. However, defining the standard of care is not the same as assessment in observational studies, and therefore, we cannot be certain if the included groups from randomized trials actually reflected daily care. Finally, because the aim of our analysis was to assess the use of low VTs in patients with healthy lungs in either the ICU or OR setting, several studies were excluded for including more than one-quarter of patients experiencing ARDS, or investigating 1-lung ventilation, or ventilation after lung transplantation or during cardiopulmonary resuscitation; investigations outside the ICU or OR were also excluded. “Uninjured lungs” were defined as “no acute lung injury or ARDS.” However, this definition did not exclude patients who experienced other pulmonary diseases, such as chronic obstructive pulmonary disease or fibrosis. Therefore, no conclusions can be made regarding these important patient groups and separate investigations are required to assess the use of potentially harmful ventilation strategies in these patients.
We included data from a total of >120,000 patients spanning a period of 40 years. Although this seems to be a very large number of patients, it covers only approximately 3000 patients per year. Many more patients receive mechanical ventilation every day on ICUs or in the ORs. Thus, our results only depict a very small proportion of patients receiving mechanical ventilation. It is possible that clinical practice differs from the studies we reviewed.
The authors wish to thank Renate Babian and Julia Övermöhle for their help with data collection, and Anne Berwanger for language editing.
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