Mechanical ventilation in critically ill pregnant women: a systematic review.
CCCF ePoster library. Twin S. Oct 3, 2017; 198146; 60
Sally Twin
Sally Twin
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Mechanical ventilation in critically ill pregnant women: a systematic review.

Viau-Lapointe J1, Twin S2, Kfouri J3, D'Souza R3,4, Rose L5, Lapinsky S1

1 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; 2 University of Waterloo, Waterloo, ON, Canada; 3 Department of Obstetrics and Gynaecology, Sinai Health System and University of Toronto, Toronto, ON, Canada; 4 Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada; 5 TD Nursing Professor in Critical Care Research, Sunnybrook Health Sciences Centre, University of Toronto and Michael Garron Hospital; Toronto, ON, Canada


INTRODUCTION: Approximately 0.2 % of pregnant women will require mechanical ventilation (MV) due to critical illness, trauma, or complications associated with pregnancy [1]. Evidence-based management recommendations are lacking and clinicians are faced with uncertainties when defining their MV plan tailored to maternal and fetal physiology [2]­.

OBJECTIVES: This systematic review aims to describe MV strategies outlined in studies of critically ill pregnant women.
 
METHODS: We performed an electronic search using MEDLINE, EMBASE, CINAHL, the Cochrane Library, PROSPERO and the Joanna Briggs Institute EBP databases (Jan 1980 to Sept 2016) using keywords and MeSH terms to identify English-language publications describing the use of invasive or non-invasive MV in pregnant women. We excluded case reports and case series reporting less than 5 women published earlier than 2002 due to publication of evidence of the benefit of lung protective ventilation. Reference lists of included articles were manually searched. Two authors independently performed title and full text screening, and data extraction.
 
RESULTS: We retrieved 5034 studies and included 74 articles for data extraction and analysis. We found 44 case reports, 29 case series, and one case control study describing a median of 1 (IQR 1-10.75) women per study (total 924 women). Acute respiratory distress syndrome was the most common reason for ventilation (46 studies, 62%),most commonly due to influenza (26/46 studies, 57%)). Other frequent indications were status asthmaticus, pneumonia, and pulmonary edema. Overall maternal mortality was 21%.
 
Non-invasive ventilation (NIV) (bi-level and continuous positive pressure ventilation) was used in 19 studies (24%) for 127 women. NIV failure, defined as need to provide invasive MV was required for 58/127 women (46%).
 
Invasive ventilation was provided to 842 women in 70 studies (95%). Ventilator parameters were specified in 62% of studies. Most frequently reported modes were volume (184 women) and pressure control ventilation (11 women). Non-conventional modes such as airway pressure release ventilation were also used  (7 women). When described, tidal volumes ranged from 5 to 10 ml/kg; positive end-expiratory pressure (PEEP) from 5 to 32 cmH2O. Few descriptions of inspiratory peak or plateau airway pressures were provided.
 
Adjunctive respiratory therapies were described in 43 studies (58%). Most frequently used were neuromuscular blocking agents (44 women); tracheostomy (33 women); venovenous extracorporeal membrane oxygenation (32 women); inhaled vasodilators (20 women); prone positioning (19 women); and high frequency oscillatory ventilation (11 women). Other therapies infrequently described were recruitment maneuvers and tracheal gas insufflation.
 
A total of 323 deliveries were described including 134 (41%) during MV of which 106 (79%) were delivered by caesarean section. The impact of delivery on respiratory function was rarely reported.
 
CONCLUSION: This systematic review describes various MV strategies used in critically ill pregnant women. There is limited evidence that MV strategies used in the general ICU population are well suited to pregnancy. Existing data are insufficient to make recommendations on how MV should be modified for the critically ill pregnant woman. 

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