Optimal Upper Limits of Plateau Pressure for Patients With Acute Respiratory Distress Syndrome During the First Seven Days: A Meta-Regression Analysis
Hideto Yasuda, Masamitsu Sanui, Tetsuro Nishimura, Tetsuro Kamo, Eishu Nango, Takayuki Abe, Rachel Roberts, Toru Takebayashi, Satoru Hashimoto, Alan Kawarai Lefor
Abstract
Background: The effects of plateau pressure during the initial days of mechanical ventilation on outcomes for patients with acute respiratory distress syndrome have not been fully examined. We conducted meta-regression analysis of plateau pressure during the first 7 days using randomized control trials to investigate the optimal upper limits of plateau pressure on different days of mechanical ventilation. Methods: Randomized controlled trials comparing two mechanical ventilation strategies with lower and higher plateau pressures in patients with acute respiratory distress syndrome were included. Meta-regression analysis was performed to determine the association of plateau pressure with mortality on days 1, 3, and 7 of mechanical ventilation. Results: After evaluation of 2,975 citations from a comprehensive search across electronic databases, 14 studies were included in the final qualitative analysis. A total of 4,984 patients were included in the quantitative analysis. As a result of the pairwise comparison, overall short-term mortality was significantly higher for patients with plateau pressures over 32 cm H 2 O during the first 3 days after intensive care unit (ICU) admission (day 1: relative risk (RR), 0.77; 95% confidence interval (CI), 0.66 - 0.89; I 2 = 0%; day 3: RR, 0.76; 95% CI, 0.64 - 0.90; I 2 = 0%), but not on day 7 (RR, 0.82; 95% CI, 0.65 - 1.04; I 2 = 16%). Plateau pressures below 27 cm H 2 O and 30 cm H 2 O were not associated with an absolute risk reduction of short-term mortality. According to univariable meta-regression analysis, mortality was significantly associated with plateau pressure on day 1 (? = 0.01 (95% CI, 0.002 - 0.024), P = 0.02). On days 3 and 7, however, no significant difference was detected. When the cutoffs were set at 27, 30 and 32 cm H 2 O on day 1, which showed a significant difference, plateau pressure tended to be associated with increased mortality at pressures above the cut-off values, and there were no significant differences at pressures below the cut-off values, regardless of the cutoff used. Conclusions: This study suggests that the optimal cut-off value for plateau pressure may be 27 cm H 2 O especially during the initial period of mechanical ventilation, although this association may not continue during the latter period of mechanical ventilation. J Clin Med Res. 2021;13(1):48-63 doi: https://doi.org/10.14740/jocmr4390