Evidence Supporting the Clinical Uses of Proportional Assist Ventilation: A Systematic Review and Meta-Analysis
CCCF ePoster library. Kumar B. Oct 3, 2017; 198102; 49
Dr. Bharath Kumar
Dr. Bharath Kumar
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Abstract
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Evidence Supporting the Clinical Uses of Proportional Assist Ventilation: A Systematic Review and Meta-Analysis

BHARATH KUMAR TIRUPAKUZHI VIJAYARAGHAVAN, CRITICAL CARE MEDICINE, SUNNYBROOK HEALTH SCIENCES CENTRE, TORONTO, CANADA; SHATHA HAMED, CRITICAL CARE MEDICINE, UNIVERSITY OF TORONTO, TORONTO, CANADA; ADITI JAIN, CRITICAL CARE MEDICINE, UNIVERSITY OF TORONTO, TORONTO, CANADA; TIMOTHY CHIMUNDA, CRITICAL CARE MEDICINE, UNIVERSITY OF TORONTO, TORONTO, CANADA; IRENE TELIAS, CRITICAL CARE MEDICINE, UNIVERSITY OF TORONTO, TORONTO, CANADA, JAN O. FRIEDRICH, CRITICAL CARE MEDICINE, ST.MICHAELS HOSPITAL AND UNIVERSITY OF TORONTO, TORONTO, CANADA; KAREN E A BURNS, CRITICAL CARE MEDICINE, ST.MICHAELS HOSPITAL AND UNIVERSITY OF TORONTO, TORONTO, CANADA;


Introduction:
Proportional Assist Ventilation (PAV) generates pressure in proportion to instantaneous effort by amplifying inspiratory effort without a preselected target in spontaneously breathing patients. PAV plus measures compliance and resistance, calculates work of breathing and elastance, and adjusts the level of support provided according to a preset level of assistance. Although PAV and PAV+ are expected to augment patient comfort and synchrony, whether they confer clinical benefits remains unknown.

Objectives: To summarize randomized controlled trials (RCTs) comparing invasive and noninvasive PAV and PAV+ in critically ill adults and children reporting clinical outcomes.

Methods:
We searched Medline (1946-Sept 2015), EMBASE (1947-Sept 2015) and CENTRAL (August 2015) to identify potentially eligible trials using database-specific search strategies.  Five authors hand-searched conference proceedings from 5 meetings (Society of Critical Care Medicine, European Society of Intensive Care Medicine, International Symposium of Intensive Care and Emergency Medicine, American College of Chest Physicians, and the American Thoracic Society) from 2005-2015. The search was not limited by language or publication status.

We selected  parallel group and crossover RCTs that enrolled critically ill adults or children receiving invasive or noninvasive PAV or PAV+, compared them to an alternate mode, and reported at least one clinically important outcome.

Results:
We identified 13 RCTs (10 parallel-group, 3 crossover) involving 881 patients. Eight trials evaluated PAV and 5 trials evaluated PAV+. Of these, 4 parallel-group RCTs evaluated noninvasive PAV in patients with acute respiratory failure (ARF). Two parallel-group trials evaluated invasive PAV as a weaning strategy. Four trials evaluated PAV+ as an initial support strategy (n=1), weaning strategy (n=2), and as an SBT technique (n=1). Three cross-over trials [2 invasive PAV and 1 invasive PAV+] assessed sleep quality. Trials were of low to moderate quality.

Compared to noninvasive Pressure Support (PS), noninvasive PAV showed a nonsignificant reduction in intubation rate [RR 0.92 (0.59,1.43); 2 trials, n=161; I2=0%] and no effect on ICU or hospital mortality or length of stay. Compared to invasive PS, we found no effect of invasive PAV on the proportion of rapid eye movement sleep [MD -2.93 (-14.20, 8.34) (percentage); 2 trials, n=50; I2=43%].  Compared to invasive PS, invasive PAV+ showed a nonsignificant increase in weaning time [MD 0.46 (-0.71,1.63); (hours )2 trials, n=74; I2 =0%].

Conclusions:
Available RCT data do not support use of invasive or noninvasive PAV or invasive PAV+ for various indications in critically ill adults. No trial evaluated PAV or PAV+ in children. Promising areas for future investigation include evaluation of (i) noninvasive PAV as initial support for patients with ARF, (ii) invasive PAV on sleep quality, and (iii) invasive PAV+ in weaning. 
 
 

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