Standardized Management for Hypoxemic Respiratory Failure and ARDS: Systematic Review & Meta-analysis.

BACKGROUND Treatment of hypoxemic respiratory failure (HRF) and Acute Respiratory Distress Syndrome (ARDS) is complex. Standardized management of HRF and ARDS may improve adherence to evidence informed practice and improve outcomes. RESEARCH QUESTION To examine the effect of standardized management compared to usual care on survival in HRF and ARDS patients. METHODS MEDLINE, 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 management (care-protocol, care-pathway, or bundle) compared with usual management among mechanically ventilated adult patients admitted to an intensive care unit (ICU) with HRF or ARDS. Study characteristics, pathway components, and patient outcomes were abstracted independently by two reviewers. RESULTS From 15,932 unique citations, 14 studies were included in the systematic review (3 RCTs 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 (RR) 0.77, 95% CI 0.65-0.91, I2 70%, p=0.002). In studies targeting ARDS patients (n=8), a 21% pooled mortality reduction was observed (RR 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 p< 0.001). 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, p<0.001). Meta-regression demonstrated that the reduction in mortality was associated with provision of lower tidal volume (p=0.045). INTERPRETATION When compared to usual management, standardized management of HRF and ARDS patients is associated with increased ventilator-free days, lower tidal volume ventilation, and lower mortality. Intensive care units should consider the use of standardized management to improve the processes and outcomes of care for patients with HRF and ARDS.