Daily Ards Research Analysis
A meta-analysis of randomized trials suggests individualized PEEP during one-lung ventilation improves oxygenation and reduces postoperative ARDS, though it does not significantly lower overall pulmonary complications. A nationwide propensity-matched cohort signals potential harm from haemoadsorption in ICU COVID-19 patients. An open-label neonatal RCT finds nasopharyngeal prongs and RAM cannula are comparable for NIPPV escalation prevention.
Summary
A meta-analysis of randomized trials suggests individualized PEEP during one-lung ventilation improves oxygenation and reduces postoperative ARDS, though it does not significantly lower overall pulmonary complications. A nationwide propensity-matched cohort signals potential harm from haemoadsorption in ICU COVID-19 patients. An open-label neonatal RCT finds nasopharyngeal prongs and RAM cannula are comparable for NIPPV escalation prevention.
Research Themes
- Personalized ventilator strategies during one-lung ventilation
- Safety of haemoadsorption in critically ill COVID-19
- Interface selection for neonatal noninvasive ventilation
Selected Articles
1. Effects of Individualized Positive End-Expiratory Pressure on Patients Undergoing One-Lung Ventilation During Thoracic Surgery: A Systematic Review and Meta-Analysis.
Across six RCTs, individualized PEEP during one-lung ventilation improved intraoperative oxygenation and compliance and reduced postoperative ARDS, but did not significantly lower overall PPCs. Trial sequential analysis indicates current evidence is underpowered and inconclusive.
Impact: Provides synthesized evidence on personalized ventilator settings in thoracic surgery and signals an ARDS reduction, informing perioperative ventilation strategy.
Clinical Implications: Consider individualized PEEP during one-lung ventilation to improve oxygenation and potentially reduce postoperative ARDS, while recognizing that overall PPCs may not decrease; implementation should await larger confirmatory trials.
Key Findings
- Individualized PEEP did not significantly reduce overall PPCs (RR 0.78; 95% CI 0.59-1.03; p=0.08).
- Postoperative ARDS was reduced with individualized PEEP.
- Intraoperative oxygenation and dynamic compliance improved with individualized PEEP.
- Trial sequential analysis showed current cumulative sample size is below the required information size and did not cross monitoring boundaries.
Methodological Strengths
- Meta-analysis restricted to randomized controlled trials
- Use of Cochrane RoB 2 tool and trial sequential analysis to assess bias and information size
Limitations
- Low overall certainty and underpowered findings per TSA
- Heterogeneity in individualized PEEP titration protocols across trials
Future Directions: Conduct adequately powered, multicenter RCTs with standardized individualized PEEP protocols, reporting ARDS and long-term clinical outcomes.
OBJECTIVE: To evaluate the impact of individualized positive end-expiratory pressure (PEEP) versus fixed PEEP on postoperative pulmonary complications (PPCs), intraoperative oxygenation, and respiratory mechanics in thoracic surgery. One-lung ventilation (OLV) poses potential risks of PPCs. PEEP may mitigate lung injury, but the optimal PEEP level remains uncertain. METHODS: We searched PubMed, Embase, Web of Science, and Cochrane for randomized controlled trials (RCTs) comparing individualized PEEP versus fixed PEEP during OLV published up to December 2024. The primary outcome was the occurrence of overall PPCs during hospitalization. Secondary outcomes included postoperative hypoxemia, atelectasis, pneumonia, acute respiratory distress syndrome (ARDS), intraoperative oxygenation, dynamic compliance, driving pressure, and hospital length of stay. Risk ratios (RRs) and mean differences were calculated using the DerSimonian-Laird method. Study quality was evaluated using the Cochrane Risk of Bias tool version 2 for RCTs trials. Trial sequential analysis (TSA) was used to assess result reliability. RESULTS: Six RCTs (with a total of 1,844 patients) were included, with 5 studies (1,814 patients) reporting PPCs. Individualized PEEP did not significantly reduce overall PPCs (RR, 0.78; 95% confidence interval, 0.59-1.03; p = 0.08), hypoxemia, pneumonia, or atelectasis; however, it reduced postoperative ARDS and improved intraoperative oxygenation and lung compliance. TSA revealed that the current sample size of 1,814 in PPCs was below the required 3,660, and that the z-curve did not cross the TSA monitoring boundaries. CONCLUSIONS: Individualized PEEP in thoracic surgery may improve intraoperative oxygenation, pulmonary mechanics, and reduce postoperative ARDS but does not significantly lower overall PPCs. Overall, the quality of the evidence is low and inconclusive, and further investigation is warranted.
2. Critical risks of haemoadsorption for COVID-19 patients and directions for future evaluations: a nationwide propensity score matched cohort study.
In a nationwide propensity-matched cohort of ICU COVID-19 patients, haemoadsorption was associated with higher in-hospital mortality and more coagulopathy, arrhythmias, and CPR events versus matched controls. Effects were harmful in patients without septic shock and did not improve survival in septic shock; timing of therapy did not modify outcomes.
Impact: Delivers a large-scale safety signal questioning routine haemoadsorption use in COVID-19 critical care and guides the design of future RCTs.
Clinical Implications: Avoid routine haemoadsorption in ICU COVID-19, especially in patients without septic shock; restrict use to rigorously designed clinical trials and monitor coagulation risks.
Key Findings
- Higher in-hospital mortality with haemoadsorption vs controls (74.6% vs 70.3%; p=0.0299).
- Increased coagulopathy (68.0% vs 54.9%; p<0.0001), cardiac arrhythmias (49.2% vs 44.2%; p=0.0272), and CPR (19.3% vs 13.1%; p=0.0002).
- Higher odds of death in patients without septic shock (OR 1.40; 95% CI 1.05-1.86) and no survival benefit in septic shock (OR 1.19; 95% CI 0.85-1.67).
- ECMO (OR 2.15; 95% CI 1.68-2.76) and CPR (OR 1.60; 95% CI 1.03-2.45) independently increased mortality.
- Timing of haemoadsorption did not influence outcomes.
Methodological Strengths
- Nationwide dataset with 1:1 propensity score matching (n=2,058 matched)
- Flexible regression with spline functions and interaction terms to address non-linearities
Limitations
- Retrospective design with potential residual confounding and indication bias
- Administrative data may lack granular clinical variables (e.g., cytokine levels, timing relative to disease trajectory)
Future Directions: Prospective, randomized trials focusing on patient selection, timing, and safety endpoints to determine if any subgroup benefits from haemoadsorption.
Haemoadsorption has been suggested as treatment adjunct for sepsis and septic shock, cardiac surgery, acute respiratory distress syndrome, and coronavirus disease 2019 (COVID-19). Randomised clinical trials did not provide conclusive evidence for benefits and even suggest risks in COVID-19 patients. Retrospective observational cohort study based on hospital remuneration data from all COVID-19 patients treated in intensive care units in Germany between 01/01/2020 and 12/31/2021. Regression modelling was performed for 1:1 propensity score matching of 2058 patients. Two-sided probability values for group comparisons and regression models with spline functions controlling for non-linear relationships and medically relevant interaction variables were calculated. In-hospital mortality of patients supported with haemoadsorption was significantly higher compared to matched control patients (74.6% vs. 70.3%, p = 0.0299). Haemoadsorption was associated with coagulopathy (68.0% vs. 54.9%, p < 0.0001), cardiac arrhythmia (49.2% vs. 44.2%, p = 0.0272), and cardiopulmonary resuscitation (CPR, 19.3% vs. 13.1%, p = 0.0002). Further, haemoadsorption increased the chance of death for COVID-19 patients without septic shock (odds ratio, OR [within a 95% confidence interval, CI]; 1.40 [1.05-1.86]) and did not improve survival of septic shock patients (1.19 [0.85-1.67]). Independent variables with a significant impact on mortality included the use of extracorporeal membrane oxygenation (ECMO, 2.15 [1.68-2.76]) and CPR (1.60 [1.03-2.45]). The timing of the haemoadsorption therapy had no effect on patients´ outcomes. Due to inconclusive evidence for benefit and potential harm, haemoadsorption therapy should be limited to thoroughly designed clinical trials before introduced into clinical routine in the context of COVID-19.
3. Nasopharyngeal Prongs versus RAM Cannula for Delivering Noninvasive Positive Pressure Ventilation: An Open-Label, Randomized Controlled Trial.
In a single-center, open-label RCT of 150 preterm neonates on NIPPV, NP prongs and RAM cannula had similar rates of invasive ventilation within 72 hours and comparable secondary outcomes, including nasal injury and duration of support.
Impact: Provides randomized comparative effectiveness evidence on commonly used neonatal NIPPV interfaces, supporting flexibility in device choice.
Clinical Implications: Either NP prongs or RAM cannula can be used for NIPPV in preterm neonates with similar efficacy; device selection may be guided by fit, availability, and caregiver experience.
Key Findings
- Invasive ventilation within 72 hours occurred in 33% (NP prongs) vs 28% (RAM cannula); RR 1.17 (95% CI 0.72-1.89); P=0.44.
- No effect modification by stratification variables on the primary outcome.
- Secondary outcomes (nasal injury incidence/severity, duration of respiratory support) were similar between groups.
Methodological Strengths
- Randomized allocation with registered protocol (CTRI/2023/07/055835)
- Comparable baseline characteristics enhancing internal validity
Limitations
- Open-label, single-center design with modest sample size
- Potential limited generalizability across settings and gestational age strata
Future Directions: Larger multicenter RCTs assessing diverse populations, comfort, cost, and long-term respiratory outcomes to refine interface selection.
OBJECTIVE: To compare the efficacy of nasopharyngeal (NP) prongs and RAM cannula in preventing the need for invasive ventilation among preterm neonates receiving noninvasive positive pressure ventilation (NIPPV). STUDY DESIGN: This was an open-label, randomized controlled trial conducted in the neonatal intensive care unit of a tertiary care hospital in India. A total of 150 neonates born at 28 RESULTS: Baseline characteristics, including birth weight, gestational age, and respiratory morbidities, were comparable between groups. Invasive ventilation within 72 hours of NIPPV initiation was required in 33% of neonates in the NP prongs group and 28% in the RAM cannula group (relative risk: 1.17, 95% CI: 0.72-1.89; P = .44). No significant interaction was observed between the primary outcome and the stratification variables. The incidence and severity of nasal injury, duration of respiratory support, and other secondary outcomes were also similar across groups. CONCLUSIONS: Among preterm neonates receiving NIPPV, NP prongs and a RAM cannula showed comparable efficacy in preventing the need for invasive ventilation. Further research is warranted to confirm these findings in larger and more diverse populations. TRIAL REGISTRATION: Clinical Trial Registry of India (CTRI/2023/07/055835).