• Ken Kuljit S Parhar, Henry T Stelfox, Kirsten M Fiest, Gordon D Rubenfeld, Danny J Zuege, Gwen Knight, Lee Robertson Helen H Health Sciences Library, Libraries and Cultural Resources, University of Calgary, Calgary, AB, Canada., Andrea Soo, Christopher J Doig, and Daniel J Niven.
• Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada. Electronic address: ken.parhar@albertahealthservices.ca.
• Chest. 2020 Dec 1; 158 (6): 2358-2369.

BackgroundTreatment of hypoxemic respiratory failure (HRF) and ARDS is complex. Standardized management of HRF and ARDS may improve adherence to evidence-informed practice and improve outcomes.Research QuestionWhat is the effect of standardized treatment compared with usual care on survival of patients with HRF and ARDS?Study Design And MethodsMEDLINE, EMBASE, Cochrane, CINAHL, Scopus, and Web-of-Science were searched (inception to 2018). Included studies were randomized clinical trials or quasi-experimental studies that examined the effect of standardized treatment (care-protocol, care-pathway, or bundle) compared with usual treatment among mechanically ventilated adult patients admitted to an ICU with HRF or ARDS. Study characteristics, pathway components, and patient outcomes were abstracted independently by two reviewers.ResultsFrom 15,932 unique citations, 14 studies were included in the systematic review (three randomized clinical trials and 11 quasi-experimental studies). Twelve studies (including 5,767 patients) were included in the meta-analysis. Standardized management of HRF was associated with a 23% relative reduction in mortality (relative risk, 0.77; 95% CI, 0.65-0.91; I2, 70%; P = .002). In studies targeting patients with ARDS (n = 8), a 21% pooled mortality reduction was observed (relative risk, 0.79; 95% CI, 0.71-0.88; I2, 3.1%). Standardized management was associated with increased 28-day ventilator-free days (weighted mean difference, 3.48 days; 95% CI, 2.43-4.54 days; P < .001). Standardized management was also associated with a reduction in tidal volume (weighted mean difference, -1.80 mL/kg predicted body weight; 95% CI, -2.80 to -0.80 mL/kg predicted body weight; P < .001). Meta-regression demonstrated that the reduction in mortality was associated with provision of lower tidal volume (P = .045).InterpretationWhen compared with usual treatment, standardized treatment of patients with HRF and ARDS is associated with increased ventilator-free days, lower tidal volume ventilation, and lower mortality. ICUs should consider the use of standardized treatment to improve the processes and outcomes of care for patients with HRF and ARDS.Clinical Trial RegistrationPROSPERO; No.: CRD42019099921; URL: www.crd.york.ac.uk/prospero/.Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

17 keywords...

hide…