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  • Guideline Summary
  • NGC:008845
  • 2011 Nov 22

Best evidence statement (BESt). Recruitment maneuvers for acute lung injury.

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]

View the original guideline documentation External Web Site Policy

This is the current release of the guideline.

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

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)

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.

References Supporting the Recommendations

Badet M, Bayle F, Richard JC, Guerin C. Comparison of optimal positive end-expiratory pressure and recruitment maneuvers during lung-protective mechanical ventilation in patients with acute lung injury/acute respiratory distress syndrome. Respir Care. 2009 Jul;54(7):847-54. PubMed External Web Site Policy

Boriosi JP, Sapru A, Hanson JH, Asselin J, Gildengorin G, Newman V, Sabato K, Flori HR. Efficacy and safety of lung recruitment in pediatric patients with acute lung injury. Pediatr Crit Care Med. 2011 Jul;12(4):431-6. PubMed External Web Site Policy

Dernaika TA, McCaffree DR. Open lung ventilation: waiting for outcome studies. Crit Care Med. 2007 Mar;35(3):961-3. PubMed External Web Site Policy

Duff JP, Rosychuk RJ, Joffe AR. The safety and efficacy of sustained inflations as a lung recruitment maneuver in pediatric intensive care unit patients. Intensive Care Med. 2007 Oct;33(10):1778-86. PubMed External Web Site Policy

Hodgson CL, Tuxen DV, Bailey MJ, Holland AE, Keating JL, Pilcher D, Thomson KR, Varma D. A positive response to a recruitment maneuver with PEEP titration in patients with ARDS, regardless of transient oxygen desaturation during the maneuver. J Intensive Care Med. 2011 Jan-Feb;26(1):41-9. PubMed External Web Site Policy

Iannuzzi M, De Sio A, De Robertis E, Piazza O, Servillo G, Tufano R. Different patterns of lung recruitment maneuvers in primary acute respiratory distress syndrome: effects on oxygenation and central hemodynamics. Minerva Anestesiol. 2010 Sep;76(9):692-8. PubMed External Web Site Policy

Kacmarek RM, Villar J. Lung recruitment maneuvers during acute respiratory distress syndrome: is it useful. Minerva Anestesiol. 2011 Jan;77(1):85-9. PubMed External Web Site Policy

Lapinsky SE, Mehta S. Bench-to-bedside review: Recruitment and recruiting maneuvers. Crit Care. 2005 Feb;9(1):60-5. [46 references] PubMed External Web Site Policy

Maa SH, Hung TJ, Hsu KH, Hsieh YI, Wang KY, Wang CH, Lin HC. Manual hyperinflation improves alveolar recruitment in difficult-to-wean patients. Chest. 2005 Oct;128(4):2714-21. PubMed External Web Site Policy

Marchenkov YV, Moroz VV, Izmajlov VV, Rodionov EP. Efficacy of alveolar recruitment maneuvers in patients with complicated thoracic trauma. Semin Cardiothorac Vasc Anesth. 2010 Dec;14(4):242-7. PubMed External Web Site Policy

Meade MO, Cook DJ, Guyatt GH, Slutsky AS, Arabi YM, Cooper DJ, Davies AR, Hand LE, Zhou Q, Thabane L, Austin P, Lapinsky S, Baxter A, Russell J, Skrobik Y, Ronco JJ, Stewart TE, Lung Open Ventilation Study Investigators. Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2008 Feb 13;299(6):637-45. PubMed External Web Site Policy

Papadakos PJ, Lachmann B, Rudolph Koch R. Lung recruitment: a role in mechanical ventilation. CJRT RCTR; 2010.

Povoa P, Almeida E, Fernandes A, Mealha R, Moreira P, Sabino H. Evaluation of a recruitment maneuver with positive inspiratory pressure and high PEEP in patients with severe ARDS. Acta Anaesthesiol Scand. 2004 Mar;48(3):287-93. PubMed External Web Site Policy

Principi T, Fraser DD, Morrison GC, Farsi SA, Carrelas JF, Maurice EA, Kornecki A. Complications of mechanical ventilation in the pediatric population. Pediatr Pulmonol. 2010 Dec 30; PubMed External Web Site Policy

Scohy TV, Bikker IG, Hofland J, de Jong PL, Bogers AJ, Gommers D. Alveolar recruitment strategy and PEEP improve oxygenation, dynamic compliance of respiratory system and end-expiratory lung volume in pediatric patients undergoing cardiac surgery for congenital heart disease. Paediatr Anaesth. 2009 Dec;19(12):1207-12. PubMed External Web Site Policy

Stiller K. Physiotherapy in intensive care: towards an evidence-based practice. Chest. 2000 Dec;118(6):1801-13. [82 references] PubMed External Web Site Policy

Toth I, Leiner T, Mikor A, Szakmany T, Bogar L, Molnar Z. Hemodynamic and respiratory changes during lung recruitment and descending optimal positive end-expiratory pressure titration in patients with acute respiratory distress syndrome. Crit Care Med. 2007 Mar;35(3):787-93. PubMed External Web Site Policy

Tusman G, Bohm SH, Tempra A, Melkun F, Garcia E, Turchetto E, Mulder PG, Lachmann B. Effects of recruitment maneuver on atelectasis in anesthetized children. Anesthesiology. 2003 Jan;98(1):14-22. PubMed External Web Site Policy

Type of Evidence Supporting the Recommendations

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

Potential Benefits

Improvement of acute lung injury and/or atelectasis

Potential Harms

Not stated

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.

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.

IOM Care Need

Getting Better

IOM Domain

Effectiveness

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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