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Guideline Summary
Guideline Title
Best evidence statement (BESt). Recruitment maneuvers for acute lung injury.
Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Recruitment maneuvers for acute lung injury. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2011 Nov 22. 6 p. [20 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Acute lung injury and/or atelectasis requiring mechanical ventilation

Guideline Category
Treatment
Clinical Specialty
Emergency Medicine
Pediatrics
Pulmonary Medicine
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Guideline Objective(s)

To evaluate, among newborn infants through adults with artificial airways that are mechanically ventilated, if recruitment maneuvers compared to conventional mechanical ventilation leads to improvement of acute lung injury and/or atelectasis

Target Population

Newborn infants through adults who are mechanically ventilated with acute lung injury and/or atelectasis

Note: Exclusion criteria include patients with increased intracranial pressure, pneumothorax and hemodynamic instability.

Interventions and Practices Considered
  1. Mechanical ventilation
  2. Recruitment maneuvers (by manual inflation bag or ventilator manipulation)
  3. Timing and duration of recruitment maneuvers
Major Outcomes Considered
  • Time to resolution of atelectasis
  • Patient, family, and staff satisfaction
  • Number of ventilator days
  • Time in intensive care unit (ICU)
  • Duration of traditional therapy
  • Costs of therapy (traditional therapy, ventilator use, and ICU stay)

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Keywords: Recruitment maneuver, pediatric, acute lung injury, mechanically ventilated, open lung technique, atelectasis, intubated, artificial airway

Databases: Medline/PubMed, MD Consult, and Google Scholar

Filters: none

Date range searched: 2000-2011

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Table of Evidence Levels

Quality Level Definition
1a or 1b Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5a or 5b General review, expert opinion, case report, consensus report, or guideline
5 Local consensus

a = good quality study; b = lesser quality study

Note: See the original guideline document for further information about the dimensions used to judge the strength of the evidence.

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Table of Recommendation Strength

Strength Definition
It is strongly recommended that…
It is strongly recommended that… not…
There is consensus that benefits clearly outweigh risks and burdens (or vice versa for negative recommendations).
It is recommended that…
It is recommended that… not…
There is consensus that benefits are closely balanced with risks and burdens.
There is insufficient evidence and a lack of consensus to make a recommendation…
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the body of evidence
  2. Safety/harm
  3. Health benefit to the patients (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

This Best Evidence Statement has been reviewed against quality criteria by 2 independent reviewers from the Cincinnati Children's Hospital Medical Center (CCHMC) Evidence Collaboration.

Recommendations

Major Recommendations

The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a‒5b) are defined at the end of the "Major Recommendations" field.

It is recommended that recruitment maneuvers (RM) be used with mechanically ventilated patients diagnosed with acute lung injury to improve acute lung injury and decrease atelectasis (Lapinsky & Mehta, 2005 [1b]; Badet et al., 2009 [2a]; Marchenkov et al., 2010 [2a]; Meade et al., 2008 [2a]; Scohy et al., 2009 [2a]; Tusman et al., 2003 [2a]; Iannuzzi et al., 2010 [2b]; Maa et al., 2005 [2b]; Boriosi et al., 2011 [3a]; Duff, Rosychuk, & Joffe, 2007 [3a]; Povoa et al., 2004 [3a]; Toth et al., 2007 [3a]; Hodgson et al., 2011 [4a]; Dernaika & McCaffree, 2007 [5a]; Kacmarek & Villar, 2011 [5a]; Papadakos, Lachmann, & Rudolph Koch, 2010 [5a]; Stiller, 2000 [5a]; Principi et al., 2011 [5b]).

Note: Potential risks for use of RM are transient hypotension, decreased venous return and barotrauma (Lapinsky & Mehta, 2005 [1b]; Marchenkov et al., 2010 [2a]; Iannuzzi et al., 2010 [2b]; Duff, Rosychuk, & Joffe, 2007 [3a]; Hodgson et al., 2011 [4a]; Dernaika & McCaffree, 2007 [5a]; Kacmarek & Villar, 2011 [5a]).

Definitions:

Table of Evidence Levels

Quality Level Definition
1a or 1b Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5a or 5b General review, expert opinion, case report, consensus report, or guideline
5 Local consensus

a = good quality study; b = lesser quality study

Note: See the original guideline document for further information about the dimensions used to judge the strength of the evidence.

Table of Recommendation Strength

Strength Definition
It is strongly recommended that…
It is strongly recommended that… not…
There is consensus that benefits clearly outweigh risks and burdens (or vice versa for negative recommendations).
It is recommended that…
It is recommended that… not…
There is consensus that benefits are closely balanced with risks and burdens.
There is insufficient evidence and a lack of consensus to make a recommendation…
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the body of evidence
  2. Safety/harm
  3. Health benefit to the patients (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Improvement of acute lung injury and/or atelectasis

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

Implementation of the Guideline

Description of Implementation Strategy

Applicability Issues

Potential applicability issues for implementation of recruitment maneuvers (RM) are development of a standardized procedure (including frequency and method) for each patient population, development of an order set and documentation and staff education.

Implementation Tools
Audit Criteria/Indicators
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Recruitment maneuvers for acute lung injury. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2011 Nov 22. 6 p. [20 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2011 Nov 22
Guideline Developer(s)
Cincinnati Children's Hospital Medical Center - Hospital/Medical Center
Source(s) of Funding

Cincinnati Children's Hospital Medical Center

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Team Leader/Author: Rhonda Schum RRT, RT II The Heart Institute

Team Members/Co-Authors: Cynthia White, BS, RRT-NPS, AE-C, RT III Respiratory Therapy Research; Abby Motz, BS, RRT-NPS, RRTIII The Heart Institute; Tracy Neff, RRT Pediatric Intensive Care Unit Sue Allgeier, AAS, RRTII Respiratory; Carmen Williams, RRT, RTIII Transitional Care Center; Cheri Purk, RRT-NPS The Heart Institute; Carla Drennen, BS, RRT-NPS Pediatric Intensive Care Unit; Jessica Young, BHS,RRT-NPS RTII; Amy Wolf, BS, RRT-NPS RTIII, Transport; Tonie Perez, BS, RRT-NPS, RRT III, Neonatal Intensive Care Unit

Support/Consultant: Barbara Giambra, RN, MS, CPNP, Evidence-Based Practice Mentor, Center for Professional Excellence, Research and Evidence-Based Practice

Financial Disclosures/Conflicts of Interest

Conflicts of interest were declared for each team member and no financial conflicts of interest were found.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Cincinnati Children's Hospital Medical Center Web site External Web Site Policy.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Availability of Companion Documents

The following are available:

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

In addition, suggested process or outcome measures are available in the original guideline document External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on March 28, 2012.

Copyright Statement

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

Copies of Cincinnati Children's Hospital Medical Center (CCHMC) External Web Site Policy Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the BESt include the following:

  • Copies may be provided to anyone involved in the organization's process for developing and implementing evidence based care
  • Hyperlinks to the CCHMC website may be placed on the organization's website
  • The BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents
  • Copies may be provided to patients and the clinicians who manage their care

Notification of CCHMC at EBDMInfo@cchmc.org for any BESt adopted, adapted, implemented or hyperlinked by the organization is appreciated.

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The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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