Does End-Expiratory Occlusion Test Predict Fluid Responsiveness in Mechanically Ventilated Patients? A Systematic Review and Meta-Analysis

Abstract

Background: We performed a systematic review and meta-analysis of studies investigating the end-expiratory occlusion (EEO) test induced changes in cardiac index (CI) and in arterial pressure as predictors of fluid responsiveness in adults receiving mechanical ventilation. Methods: MEDLINE, EMBASE, Cochrane Database, and Chinese database were screened for relevant original and review articles. The meta-analysis determined the pooled sensitivity, specificity, diagnostic odds ratio, area under the receiver operating characteristic curve (AUROC), and threshold for the EEO test assessed with CI and arterial pressure. In addition, heterogeneity and subgroup analyses were performed. Results: We included 13 studies involving 479 adult patients and 523 volume expansion. Statistically significant heterogeneity was identified, and meta-regression indicated that prone position was the major sources of heterogeneity. After removal of the study performed in prone position, heterogeneity became nonsignificant. EEO-induced changes in CI (or surrogate) are accurate for predicting fluid responsiveness in semirecumbent or supine patients, with excellent pooled sensitivity of 92% (95% CI, 0.88–0.95, I2 = 0.00%), specificity of 89% (95% CI, 0.83–0.93, I2 = 34.34%), and a summary AUROC of 0.95 (95% CI, 0.93–0.97). The mean threshold was an EEO-induced increase in CI (or surrogate) of more than 4.9 ± 1.5%. EEO test exhibited better diagnostic performance in semirecumbent or supine patients than prone patients, with higher AUROC (0.95 vs. 0.65; P < 0.001). In addition, EEO test exhibited higher specificity (0.93 vs. 0.83, P < 0.001) in patients ventilated with low tidal volume compared with normal or nearly normal tidal volume. However, EEO test was less accurate when its hemodynamic effects were detected on arterial pressure. EEO-induced changes in arterial pressure exhibited a lower sensitivity (0.88 vs. 0.92; P = 0.402), specificity (0.77 vs. 0.90; P = 0.019), and AUROC (0.87 vs. 0.96; P < 0.001) compared with EEO-induced changes in CI (or surrogate). Conclusions: EEO test is accurate to predict fluid responsiveness in semirecumbent or supine patients but not in prone patients. EEO test exhibited higher specificity in patients ventilated with low tidal volume, and its accuracy is better when its hemodynamic effects are assessed by direct measurement of CI than by the arterial pressure.

Does tidal volume challenge improve the feasibility of pulse pressure variation in patients mechanically ventilated at low tidal volumes? A systematic review and meta-analysis

“…Different clinical settings were also accountable, but we disagreed with Shi et al [ 22 ] who accounted the contradictory results to lung compliance since we found TVC was unaffected by reduced lung compliance. Besides, recent meta-analysis of EEO, the similar theory of heart–lung interaction functional test to TVC, was also proved to be limited in prone position [ 42 ].…”

Methods of assessing fluid responsiveness in septic shock patients: a narrative review

“…The threshold for SV change for FR has been 5% ( Table 1 ) [ 42 , 58 , 60 , 61 ], and the accuracy of EEOT, regardless of ventilator settings and me-thods of CO (SV) measurement, has been confirmed by a recent meta-analyses [ 20 , 57 , 61 ]. The reliability may be affected when the test was performed in a prone position, as indicated by a previous study [ 61 ].…”

“…The in terruption of this effect at the end of the expiration phase for at least 12 s [57] results in increased venous return (VR) that results in increased SV; however, other studies indicate a longer expiration phase at 15 s [58,59]. The threshold for SV change for FR has been 5% (Table 1) [42,58,60,61], and the accuracy of EEOT, regardless of ventilator settings and me thods of CO (SV) measurement, has been confirmed by a re cent metaanalyses [20,57,61]. The reliability may be affected when the test was performed in a prone po sition, as indicated by a previous study [61].…”

ISCCM Guidelines for Hemodynamic Monitoring in the Critically Ill

“…Messina et al conducted a meta-analyses and systematic review to check the reliability of the EEOT and of the mini-fluid challenge for predicting fluid responsiveness. 67 The areas under the curve (AUC) for EEOT was 0.96, with pooled sensitivity and specificity of 0.86 and 0.91, respectively. They concluded that EEOT and the mini-FC reliably predict fluid responsiveness.…”