Log in | Register

Enteral omega-3 fatty acid supplementation in adult patients with acute respiratory distress syndrome: a systematic review of randomized controlled trials with meta-analysis and trial sequential analysis

Daojun Zhu| Yi Zhang| Shuo Li| Lu Gan| Huaizhi Feng| Wei Nie
Systematic Review
Volume 40, Issue 4 / April , 2014

Pages 504 - 512

Abstract

Purpose

Controversy remains as to whether enteral supplementation of ω-3 fatty acids (FA) could improve outcomes in patients with acute respiratory distress syndrome (ARDS). Thus, we did a meta-analysis and aimed to investigate the benefit and harm of enteral ω-3 FA supplementation in adult patients with ARDS.

Methods

Databases including PubMed, Embase, the Cochrane Register of Controlled Trials, and Google Scholar were searched to find relevant articles. Randomized controlled trials (RCTs) comparing enteral ω-3 FA supplementation with a control or placebo intervention in adult patients with ARDS were included. The primary outcome was all-cause 28-day mortality. We used the Cochrane Collaboration methodology.

Results

Seven RCTs with 955 adult patients qualified for inclusion, and all the selected trials were considered as at high risk of bias. The use of enteral ω-3 FA did not significantly reduce all-cause 28-day mortality [relative risk (RR), 0.90; 95 % confidence intervals (CI), 0.68–1.18; p = 0.44; I2 = 31 %; random effects]. Trial sequential analysis indicated lack of firm evidence for a 20 % RR reduction in all-cause 28-day mortality. PaO2/FiO2 ratio was significantly increased in the ω-3 FA group on day 4 [weighted mean difference (WMD), 45.14; 95 % CI, 16.77–73.51; p = 0.002; I2 = 86 %; random effects] and day 7 (WMD, 33.10; 95 % CI, 1.67–64.52; p = 0.04; I2 = 88 %; random effects). Meta-analysis using a random effects model showed no significant differences in ventilator-free days (VFD) (WMD, 2.47 days; 95 % CI, −2.85 to 7.79; p = 0.36; I2 = 91 %) or intensive care unit-free days (ICU) (WMD, 2.31 days; 95 % CI, −2.34 to 6.97; p = 0.33; I2 = 89 %) between the two groups.

Conclusions

Among patients with ARDS, enteral supplementation of ω-3 FA seemed ineffective regarding all-cause 28-day mortality, VFD, and ICU-free days. Routine use of enteral ω-3 FA cannot be recommended based on the available evidence.

Keywords

References

  1. Villar J, Pérez-Méndez L, Blanco J, Añón JM, Blanch L, Belda J, Santos-Bouza A, Fernández RL, Kacmarek RM (2013) Spanish Initiative for Epidemiology, Stratification, and Therapies for ARDS (SIESTA) Network: A universal definition of ARDS: the PaO2/FiO2 ratio under a standard ventilatory setting––a prospective, multicenter validation study. Intensive Care Med 39(4):583–592
  2. Ferguson ND, Fan E, Camporota L, Antonelli M, Anzueto A, Beale R, Brochard L, Brower R, Esteban A, Gattinoni L, Rhodes A, Slutsky AS, Vincent JL, Rubenfeld GD, Thompson BT, Ranieri VM (2012) The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med 38:1573–1582
  3. Stapleton RD, Wang BM, Hudson LD, Rubenfeld GD, Caldwell ES, Steinberg KP (2005) Causes and timing of death in patients with ARDS. Chest 128:525–532
    • View reference on PubMed
    • View reference on publisher's website
  4. Villar J, Blanco J, Anon JM, Santos-Bouza A, Blanch L, Ambros A, Gandia F, Carriedo D, Mosteiro F, Basaldua S, Fernandez RL, Kacmarek RM (2011) The ALIEN study: incidence and outcome of acute respiratory distress syndrome in the era of lung protective ventilation. Intensive Care Med 37:1932–1941
  5. Rubenfeld GD, Caldwell E, Peabody E, Weaver J, Martin DP, Neff M, Stern EJ, Hudson LD (2005) Incidence and outcomes of acute lung injury. N Engl J Med 353:1685–1693
    • View reference on PubMed
    • View reference on publisher's website
  6. McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G (2009) Guidelines for the provision and assessment of nutrition support therapy in the adult critically III patient: society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 33:277–316
    • View reference on PubMed
    • View reference on publisher's website
  7. Pacht ER, DeMichele SJ, Nelson JL, Hart J, Wennberg AK, Gadek JE (2003) Enteral nutrition with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants reduces alveolar inflammatory mediators and protein influx in patients with acute respiratory distress syndrome. Crit Care Med 31:491–500
    • View reference on PubMed
    • View reference on publisher's website
  8. Pontes-Arruda A, Demichele S, Seth A, Singer P (2008) The use of an inflammation-modulating diet in patients with acute lung injury or acute respiratory distress syndrome: a meta-analysis of outcome data. JPEN J Parenter Enteral Nutr 32:596–605
    • View reference on PubMed
    • View reference on publisher's website
  9. Grau-Carmona T, Moran-Garcia V, Garcia-de-Lorenzo A, Heras-de-la-Calle G, Quesada-Bellver B, Lopez-Martinez J, Gonzalez-Fernandez C, Montejo-Gonzalez JC, Blesa-Malpica A, Albert-Bonamusa I, Bonet-Saris A, Herrero-Meseguer JI, Mesejo A, Acosta J (2011) Effect of an enteral diet enriched with eicosapentaenoic acid, gamma-linolenic acid and anti-oxidants on the outcome of mechanically ventilated, critically ill, septic patients. Clin Nutr 30:578–584
    • View reference on PubMed
    • View reference on publisher's website
  10. Rice TW, Wheeler AP, Thompson BT, deBoisblanc BP, Steingrub J, Rock P (2011) Enteral omega-3 fatty acid, gamma-linolenic acid, and antioxidant supplementation in acute lung injury. JAMA 306:1574–1581
    • View reference on PubMed
    • View reference on publisher's website
  11. Stapleton RD, Martin TR, Weiss NS, Crowley JJ, Gundel SJ, Nathens AB, Akhtar SR, Ruzinski JT, Caldwell E, Curtis JR, Heyland DK, Watkins TR, Parsons PE, Martin JM, Wurfel MM, Hallstrand TS, Sims KA, Neff MJ (2011) A phase II randomized placebo-controlled trial of omega-3 fatty acids for the treatment of acute lung injury. Crit Care Med 39:1655–1662
    • View reference on PubMed
    • View reference on publisher's website
  12. Elamin EM, Miller AC, Ziad S (2012) Immune enteral nutrition can improve outcomes in medical-surgical patients with ARDS: a prospective randomized controlled trial. J Nutr Disord Ther 2:109. doi:10.4172/jndt.1000109
  13. Higgins JPT, Green S (2011) Cochrane handbook for systematic reviews of interventions Version 5.1.0. The Cochrane Collaboration. http://handbook.cochrane.org. Accessed 28 Jan 2014
  14. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 62:1006–1012
    • View reference on publisher's website
  15. Higgins JP, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21:1539–1558
    • View reference on PubMed
    • View reference on publisher's website
  16. Calder PC (2010) The 2008 ESPEN Sir David Cuthbertson Lecture: fatty acids and inflammation––from the membrane to the nucleus and from the laboratory bench to the clinic. Clin Nutr 29:5–12
    • View reference on PubMed
    • View reference on publisher's website
  17. Altman DG, Bland JM (2003) Interaction revisited: the difference between two estimates. BMJ 326:219
    • View reference on PubMed
    • View reference on publisher's website
  18. Sweeting MJ, Sutton AJ, Lambert PC (2004) What to add to nothing? Use and avoidance of continuity corrections in meta-analysis of sparse data. Stat Med 23:1351–1375
    • View reference on PubMed
    • View reference on publisher's website
  19. Brok J, Thorlund K, Gluud C, Wetterslev J (2008) Trial sequential analysis reveals insufficient information size and potentially false positive results in many meta-analyses. J Clin Epidemiol 61:763–769
    • View reference on PubMed
    • View reference on publisher's website
  20. Wetterslev J, Thorlund K, Brok J, Gluud C (2009) Estimating required information size by quantifying diversity in random-effects model meta-analyses. BMC Med Res Methodol 9:86
    • View reference on PubMed
    • View reference on publisher's website
  21. Gadek JE, DeMichele SJ, Karlstad MD, Pacht ER, Donahoe M, Albertson TE, Van Hoozen C, Wennberg AK, Nelson JL, Noursalehi M (1999) Effect of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in patients with acute respiratory distress syndrome. Enteral Nutrition in ARDS Study Group. Crit Care Med 27:1409–1420
    • View reference on PubMed
    • View reference on publisher's website
  22. Pontes-Arruda A, Aragao AM, Albuquerque JD (2006) Effects of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and septic shock. Crit Care Med 34:2325–2333
    • View reference on PubMed
    • View reference on publisher's website
  23. Singer P, Theilla M, Fisher H, Gibstein L, Grozovski E, Cohen J (2006) Benefit of an enteral diet enriched with eicosapentaenoic acid and gamma-linolenic acid in ventilated patients with acute lung injury. Crit Care Med 34:1033–1038
    • View reference on PubMed
    • View reference on publisher's website
  24. Manzanares W, Dhaliwal R, Jurewitsch B, Stapleton RD, Jeejeebhoy KN, Heyland DK (2013) Alternative lipid emulsions in the critically ill: a systematic review of the evidence. Intensive Care Med 39:1683–1694
  25. Lekka ME, Liokatis S, Nathanail C, Galani V, Nakos G (2004) The impact of intravenous fat emulsion administration in acute lung injury. Am J Respir Crit Care Med 169:638–644
    • View reference on PubMed
    • View reference on publisher's website
  26. Zambon M, Vincent JL (2008) Mortality rates for patients with acute lung injury/ARDS have decreased over time. Chest 133:1120–1127
    • View reference on PubMed
    • View reference on publisher's website
  27. Antonelli M, Bonten M, Chastre J, Citerio G, Conti G, Curtis JR, De Backer D, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Rocco P, Timsit JF, Wernerman J, Zhang H (2012) Year in review in Intensive Care Medicine 2011: III. ARDS and ECMO, weaning, mechanical ventilation, noninvasive ventilation, pediatrics and miscellanea. Intensive Care Med 38:542–556
  28. Umezawa Makikado LD, Flordelís Lasierra JL, Pérez-Vela JL, Montejo González JC (2013) Nutrition support during extracorporeal membrane oxygenation (ECMO) in adults. Intensive Care Med 39(12):2240
  29. Giudetti AM, Cagnazzo R (2012) Beneficial effects of n-3 PUFA on chronic airway inflammatory diseases. Prostaglandins Other Lipid Mediat 99:57–67
    • View reference on PubMed
    • View reference on publisher's website
  30. Ciani O, Buyse M, Garside R, Pavey T, Stein K, Sterne JA, Taylor RS (2013) Comparison of treatment effect sizes associated with surrogate and final patient relevant outcomes in randomised controlled trials: meta-epidemiological study. BMJ 346:f457
    • View reference on PubMed
    • View reference on publisher's website

Sign In

Connect with ICM

Top 5 Articles Editors Picks Supplement