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Recruitment Maneuvers for Acute Lung Injury

A Systematic Review

¹ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; ² Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland; and ³ Departments of Clinical Epidemiology and Biostatistics, and Medicine, McMaster University, Hamilton, Ontario, Canada

Correspondence and requests for reprints should be addressed to Niall D. Ferguson, M.D., M.Sc., Toronto Western Hospital, 399 Bathurst Street, 2MCL-411M Toronto, Ontario, Canada M5T 2S8. E-mail: n.ferguson{at}utoronto.ca

Rationale: There are conflicting data regarding the safety and efficacy of recruitment maneuvers (RMs) in patients with acute lung injury (ALI).

Objectives: To summarize the physiologic effects and adverse events in adult patients with ALI receiving RMs.

Methods: Systematic review of case series, observational studies, and randomized clinical trials with pooling of study-level data.

Measurements and Main Results: Forty studies (1,185 patients) met inclusion criteria. Oxygenation (31 studies; 636 patients) was significantly increased after an RM (Pa_O2: 106 versus 193 mm Hg, P = 0.001; and Pa_O2/FI_O2 ratio: 139 versus 251 mm Hg, P < 0.001). There were no persistent, clinically significant changes in hemodynamic parameters after an RM. Ventilatory parameters (32 studies; 548 patients) were not significantly altered by an RM, except for higher PEEP post-RM (11 versus 16 cm H₂O; P = 0.02). Hypotension (12%) and desaturation (9%) were the most common adverse events (31 studies; 985 patients). Serious adverse events (e.g., barotrauma [1%] and arrhythmias [1%]) were infrequent. Only 10 (1%) patients had their RMs terminated prematurely due to adverse events.

Conclusions: Adult patients with ALI receiving RMs experienced a significant increase in oxygenation, with few serious adverse events. Transient hypotension and desaturation during RMs is common but is self-limited without serious short-term sequelae. Given the uncertain benefit of transient oxygenation improvements in patients with ALI and the lack of information on their influence on clinical outcomes, the routine use of RMs cannot be recommended or discouraged at this time. RMs should be considered for use on an individualized basis in patients with ALI who have life-threatening hypoxemia.

Key Words: artificial respiration • adult respiratory distress syndrome • respiratory physiology • systematic review

AT A GLANCE COMMENTARY Scientific Knowledge on the Subject Conflicting data exist regarding the safety and efficacy of recruitment maneuvers in patients with acute lung injury. Recruitment maneuvers lead to a significant increase in oxygenation, with few serious adverse events. What this Study Adds to the Field Given the uncertain benefit of transient oxygenation improvements in patients with ALI and the lack of information on their influence on clinical outcomes, the routine use of RMs cannot be recommended or discouraged at this time. RMs should be considered for use on an individualized basis in patients with ALI who have life-threatening hypoxemia.

 

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