Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Critical Care
Published in: Critical Care 1/2017

Open Access 01-12-2017 | Research

Heat and moisture exchangers (HMEs) and heated humidifiers (HHs) in adult critically ill patients: a systematic review, meta-analysis and meta-regression of randomized controlled trials

Authors: Maria Vargas, Davide Chiumello, Yuda Sutherasan, Lorenzo Ball, Antonio M. Esquinas, Paolo Pelosi, Giuseppe Servillo

Published in: Critical Care | Issue 1/2017

Login to get access

Abstract

Background

The aims of this systematic review and meta-analysis of randomized controlled trials are to evaluate the effects of active heated humidifiers (HHs) and moisture exchangers (HMEs) in preventing artificial airway occlusion and pneumonia, and on mortality in adult critically ill patients. In addition, we planned to perform a meta-regression analysis to evaluate the relationship between the incidence of artificial airway occlusion, pneumonia and mortality and clinical features of adult critically ill patients.

Methods

Computerized databases were searched for randomized controlled trials (RCTs) comparing HHs and HMEs and reporting artificial airway occlusion, pneumonia and mortality as predefined outcomes. Relative risk (RR), 95% confidence interval for each outcome and I 2 were estimated for each outcome. Furthermore, weighted random-effect meta-regression analysis was performed to test the relationship between the effect size on each considered outcome and covariates.

Results

Eighteen RCTs and 2442 adult critically ill patients were included in the analysis. The incidence of artificial airway occlusion (RR = 1.853; 95% CI 0.792–4.338), pneumonia (RR = 932; 95% CI 0.730–1.190) and mortality (RR = 1.023; 95% CI 0.878–1.192) were not different in patients treated with HMEs and HHs. However, in the subgroup analyses the incidence of airway occlusion was higher in HMEs compared with HHs with non-heated wire (RR = 3.776; 95% CI 1.560–9.143). According to the meta-regression, the effect size in the treatment group on artificial airway occlusion was influenced by the percentage of patients with pneumonia (β = -0.058; p = 0.027; favors HMEs in studies with high prevalence of pneumonia), and a trend was observed for an effect of the duration of mechanical ventilation (MV) (β = -0.108; p = 0.054; favors HMEs in studies with longer MV time).

Conclusions

In this meta-analysis we found no superiority of HMEs and HHs, in terms of artificial airway occlusion, pneumonia and mortality. A trend favoring HMEs was observed in studies including a high percentage of patients with pneumonia diagnosis at admission and those with prolonged MV. However, the choice of humidifiers should be made according to the clinical context, trying to avoid possible complications and reaching the appropriate performance at lower costs.
Appendix
Available only for authorised users
Literature
1.
American Association for Respiratory Care, Restrepo RD, Walsh BK. Humidification during invasive and noninvasive mechanical ventilation: 2012. Respir Care. 2012;57(5):782–8.CrossRef
2.
Branson RD, Chatburn RL. Humidification of inspired gases during mechanical ventilation. Respir Care. 1993;38:461–8.
3.
Lellouche F, Qader S, Taille S, Lyazidi A, Brochard L. Influence of ambient temperature and moisture ventilation on passive and active heat and moisture exchange. Respir Care. 2014;59(5):637–43.CrossRefPubMed
4.
5.
6.
7.
8.
Peters JL, Sutton AJ, Jones DR, Abrams KR, Rushton L. Comparison of two methods to detect publication bias in meta-analysis. JAMA. 2006;295(6):676–80.CrossRefPubMed
9.
Bissonnette B. Passive or active inspired gas humidification increases thermal steady-state temperatures in anesthetized infants. Anesth Analg. 1989;69(6):783–7.CrossRefPubMed
10.
Bissonette B, Sessler DI, La Flamme P. Passive and active inspired gas humidification in infants and children. Anesthesiology. 1989;71(3):350–4.CrossRef
11.
Campbell RS, Davis Jr K, Johannigman JA, Branson RD. The effects of passive humidifier dead space on respiratory variables in paralyzed and spontaneously breathing patients. Respir Care. 2000;45(3):306–12.PubMed
12.
Deriaz H, Fiez N, Lienhart A. Comparative effects of a hygrophobic filter and a heated humidifier on intraoperative hypothermia. Ann Fr Anesth Reanim. 1992;11(2):145–9.CrossRefPubMed
13.
Girault C, Breton L, Richard J, Tamion F, Vandelet P, Aboab J, et al. Mechanical effects of airway humidification devices in difficult to wean patients. Crit Care Med. 2003;31(5):1306–11.CrossRefPubMed
14.
Goldberg ME, Epstein R, Rosenblum F, Larijani GE, Marr A, Lessin J, et al. Do heated humidifiers and heat and moisture exchangers prevent temperature drop during lower abdominal surgery? J Clin Anesth. 1992;4(1):16–20.CrossRefPubMed
15.
Iotti GA, Olivei MC, Palo A, Galbusera C, Veronesi R, Comelli A, et al. Unfavorable mechanical effects of heat and moisture exchangers in ventilated patients. Intensive Care Med. 1997;23(4):399–405.CrossRefPubMed
16.
Le Bourdelles G, Mier L, Fiquet B, Djedaini K, Saumon G, Coste F, et al. Comparison of the effects of heat and moisture exchangers and heated humidifiers on ventilation and gas exchange during weaning trials from mechanical ventilation. Chest. 1996;110(5):1294–8.CrossRefPubMed
17.
Linko K, Honkavaara P, Nieminen MT. Heated humidification in major abdominal surgery. Eur J Anaesthesiol. 1984;1(3):285–91.PubMed
18.
MacIntyre NR, Anderson HR, Silver RM, Schuler FR, Coleman RE. Pulmonary function in mechanically ventilated patients during 24-hour use of a hygroscopic condensor humidifier. Chest. 1983;84(5):560–4.CrossRefPubMed
19.
Martin C, Papazian L, Perrin G, Saux P, Gouin F. Preservation of humidity and heat of respiratory gases in patients with a minute ventilation greater than 10 L/min. Crit Care Med. 1994;22(11):1871–6.CrossRefPubMed
20.
Pelosi P, Solca M, Ravagnan I, Tubiolo D, Ferrario L, Gattinoni L. Effects of heat and moisture exchangers on minute ventilation, ventilatory drive, and work of breathing during pressure-support ventilation in acute respiratory failure. Crit Care Med. 1996;24(7):1184–8.CrossRefPubMed
21.
Ricard JD, Markowicz P, Djedaini K, Mier L, Coste F, Dreyfuss D. Bedside evaluation of efficient airway humidification during mechanical ventilation of the critically ill. Chest. 1999;115(6):1646–52.CrossRefPubMed
22.
Roustan JP, Kienlen J, Aubas S, Du Cailar J. Evaluation of an exchange filter on heat and humidity in long duration mechanical ventilation. Comparison with heated humidification. Ann Fr Anesth Reanim. 1989;8 Suppl:R275.
23.
Thomachot L, Viviand X, Lagier P, Dejode JM, Albanese J, Martin C. Measurement of tracheal temperature is not a reliable index of total respiratory heat loss in mechanically ventilated patients. Crit Care. 2001;5(1):24–30.CrossRefPubMed
24.
Alagar R. Heated humidification reduces saline instillations, nebulized therapy, and cost in long term ventilated patients (abstract). American Journal of Respiratory and Critical Care Medicine. American Thoracic Society 2000 International Conference; May 5-10; Toronto, Canada. 2000; Vol. 161; 3 Suppl: A552.
25.
Branson RD, Davis Jr K, Campbell RS, Johnson DJ, Porembka DT. Humidification in the intensive care unit: prospective study of a new protocol utilizing heated humidification and a hydroscopic condenser humidifier. Chest. 1993;104(6):1800–05.CrossRefPubMed
26.
Branson RD, Campbell RS, Johannigman JA, Ottaway M, Davis Jr K, Luchette FA, et al. Comparison of conventional heated humidification with a new active hygroscopic heat and moisture exchanger in mechanically ventilated patients. Respir Care. 1999;44(8):912–17.
27.
Christiansen S, Renzing K, Hirche H, Reidemeister JC. Measurements of inspired air humidity as provided by different humidifiers. Anasthesiol Intensivmed Notfallmed Schmerzther. 1998;33(5):300–5.CrossRefPubMed
28.
Cohen IL, Weinberg PF, Fein IA, Rowinski GS. Endotracheal tube occlusion associated with the use of heat and moisture exchangers in the intensive care unit. Crit Care Med. 1988;16(3):277–9.CrossRefPubMed
29.
Conti G, De Blasi RA, Rocco M, Pelaia P, Antonelli M, Bufi M, et al. Effects of the heat-moisture exchangers on dynamic hyperinflation of mechanically ventilated COPD patients. Intensive Care Med. 1990;16(7):441–3.CrossRefPubMed
30.
Dias MD, Pellacine EN, Zechineli CA. The new system of gaseous mixture humidification and heating of respirators: comparative study. Rev Assoc Med Bras. 1993;39(4):207–12.PubMed
31.
Dias MD, Pellacine EN, Zechineli CA. Bacterial aerosol generated by mechanical ventilators: comparative study. Rev Assoc Med Bras. 1997;43(1):15–20.CrossRefPubMed
32.
Fujita Y, Imanaka H, Fujino Y, Takeuchi M, Tomita T, Mashimo T, Nishimura M. Effect of humidifying devices on the measurement of tidal volume by mechanical ventilators. J Anesth. 2006;20(3):166–72.CrossRefPubMed
33.
Jaber S, Pigeot J, Fodil R, Maggiore S, Harf A, Isabey D, et al. Long-term effects of different humidification systems on endotracheal tube patency: evaluation by the acoustic reflection method. Anesthesiology. 2004;100(4):782–8.CrossRefPubMed
34.
Johnson PA, Raper RF, Fisher MDM. The impact of heat and moisture exchanging humidifiers on work of breathing. Anaesth Intensive Care. 1995;23(6):697–701.PubMed
35.
Kranabetter R, Leier M, Kammermeier D, Just HM, Heuser D. The effects of active and passive humidification on ventilation-associated nosocomial pneumonia. Anaesthesist. 2004;53(1):29–35.CrossRefPubMed
36.
Lellouche F, Qader S, Taille S, Lyazidi A, Brochard L. Under-humidification and over-humidification during moderate induced hypothermia with usual devices. Intensive Care Med. 2006;32(7):1014–21.CrossRefPubMed
37.
Luchetti M, Pigna A, Gentili A, Marraro G. Evaluation of the efficiency of heat and moisture exchangers during paediatric anaesthesia. Paediatr Anaesth. 1999;9(1):39–45.CrossRefPubMed
38.
MacLeod R, Bucknall T. Mechanical ventilation with heated humidifiers or with heat and moisture exchangers with microbiological filters did not reduce ventilator associated pneumonia in adults. Evid Based Nursing. 2006;9(3):82.CrossRef
39.
Martin C, Papazian L, Perrin G, Bantz P, Gouin F. Performance evaluation of three vaporizing humidifiers and two heat and moisture exchangers in patients with minute ventilation > 10 L/min. Chest. 1992;102(5):1347–50.CrossRefPubMed
40.
Martin C, Thomachot L, Quinio B, Viviand X, Albanese J. Comparing two heat and moisture exchangers with one vaporizing humidifier in patients with minute ventilation greater than 10 L/min. Chest. 1995;107(5):1411–5.CrossRefPubMed
41.
McEvoy MT, Carey TJ. Shivering and rewarming after cardiac surgery: comparison of ventilator circuits with humidifier and heated wires to heat and moisture exchangers. Am J Crit Care. 1995;4(4):293–9.PubMed
42.
Nakagawa NK, Macchione M, Petrolino HM, Guimaraes ET, King M, Saldiva PH, et al. Effects of a heat and moisture exchanger and a heated humidifier on respiratory mucus in patients undergoing mechanical ventilation. Crit Care Med. 2000;28(2):312–7.CrossRefPubMed
43.
Prat G, Renault A, Tonnelier JM, Goetghebeur D, Oger E, Boles JM, et al. Influence of the humidification device during acute respiratory distress syndrome. Intensive Care Med. 2003;29(12):2211–5.CrossRefPubMed
44.
Prin S, Chergui K, Augarde R, Page B, Jardin F, Vieillard- Baron A. Ability and safety of a heated humidifier to control hypercapnic acidosis in severe ARDS. Intensive Care Med. 2002;28(12):1756–60.CrossRefPubMed
45.
Rathgeber J, Henze D, Zuchner K. Air conditioning with a high-performance HME (heat and moisture exchanger) − an effective and economical alternative to active humidifiers in ventilated patients. A prospective and randomized clinical study. Anaesthesist. 1996;45(6):518–25.CrossRefPubMed
46.
Rathgeber J, Betker T, Zuchner K. Measurement of water vapour pressure in the airways of mechanically ventilated patient using different types of humidifier. Anasthesiol Intensivmed Notfallmed Schmerzther. 2001;36(9):560–5.CrossRefPubMed
47.
Schiffmann H, Rethgeber J, Singer D, Harms K, Bolli A, Zuchner K. Airway humidification in mechanically ventilated neonates and infants: A comparative study of a heat and moisture exchanger vs. a heated humidifier using a new fast-response capacitive humidity sensor. Crit Care Med. 1997;25(10):1755–60.CrossRefPubMed
48.
Takumi Y, Aochi O. Effect of emphysematous expansion and humidification on the intrapulmonary gas exchange. Anaesthesist. 1970;19(10):373–83.PubMed
49.
Thomachot L, Viviand X, Arnaud S, Vialet R, Albanese J, Martin C. Preservation of humidity and heat of respiratory gases in spontaneously breathing, tracheostomized patients. Acta Anaesthesiol Scand. 1998;42(7):841–4.CrossRefPubMed
50.
Wilmshurst JM, Rahman MA, Shah V, Elton P, Long D, Martin N. The heat moisture exchange device (HME) in neonatal ventilation. Am J Perinatol. 1999;16(1):13–6.CrossRefPubMed
51.
Boyer A, Vargas F, Hilbert G, Gruson D, Mousset-Hovaere M, Castaing Y, Dreyfuss D, Ricard JD. Small dead space heat and moisture exchangers do not impede gas exchange during noninvasive ventilation: a comparison with a heated humidifier. Intensive Care Med. 2010;36(8):1348–54.CrossRefPubMed
52.
Arieli R, Daskalovic Y, Ertracht O, Arieli Y, Adir Y, Abramovich A, Halpern P. Flow resistance, work of breathing of humidifiers, and endotracheal tubes in the hyperbaric chamber. Am J Emerg Med. 2011;29(7):725–30.CrossRefPubMed
53.
Thille AW, Bertholon JF, Becquemin MH, Roy M, Lyazidi A, Lellouche F, Pertusini E, Boussignac G, Maître B, Brochard L. Aerosol delivery and humidification with the Boussignac continuous positive airway pressure device. Respir Care. 2011;56(10):1526–32.CrossRefPubMed
54.
Retamal J, Castillo J, Bugedo G, Bruhn A. Airway humidification practices in Chilean intensive care units. Rev Med Chil. 2012;140(11):1425–30.CrossRefPubMed
55.
Tonnelier A, Lellouche F, Bouchard PA, L’Her E. Impact of humidification and nebulization during expiratory limb protection: an experimental bench study. Respir Care. 2013;58(8):1315–22.CrossRefPubMed
56.
Schena E, Saccomandi P, Cappelli S, Silvestri S. Mechanical ventilation with heated humidifiers: measurements of condensed water mass within the breathing circuit according to ventilatory settings. Physiol Meas. 2013;34(7):813–21.CrossRefPubMed
57.
Ehrmann S, Roche-Campo F, Sferrazza Papa GF, Isabey D, Brochard L, Apiou-Sbirlea G. REVA research network. Aerosol therapy during mechanical ventilation: an international survey. Intensive Care Med. 2013;39(6):1048–56.CrossRefPubMed
58.
Alonso-Iñigo JM, Almela A, Albert A, Carratalá JM, Fas MJ. Active humidification with Boussignac CPAP: in vitro study of a new method. Respir Care. 2013;58(4):647–54.PubMed
59.
Schena E, Quaranta A, Saccomandi P, Silvestri S. Performances of heated humidifiers in mechanical ventilation: a preliminary intra-breath analysis. Conf Proc IEEE Eng Med Biol Soc. 2013;2013:934–7.PubMed
60.
Lellouche F, Pignataro C, Maggiore SM, Girou E, Deye N, Taillé S, Fischler M, Brochard L. Short-term effects of humidification devices on respiratory pattern and arterial blood gases during noninvasive ventilation. Respir Care. 2012;57(11):1879–86.CrossRefPubMed
61.
Schena E, Saccomandi P, Ramandi C, Silvestri S. A novel control strategy to improve the performances of heated wire humidifiers inartificial neonatal ventilation. Physiol Meas. 2012;33(7):1199–211.CrossRefPubMed
62.
Morán I, Cabello B, Manero E, Mancebo J. Comparison of the effects of two humidifier systems on endotracheal tube resistance. Intensive Care Med. 2011;37(11):1773–9.CrossRefPubMed
63.
Schena E, De Paolis E, Silvestri S. Gas pre-warming for improving performances of heated humidifiers in neonatal ventilation. Conf Proc IEEE Eng Med Biol Soc. 2011;2011:1205–8.PubMed
64.
Lorente L, Blot S, Rello J. New issues and controversies in the prevention of ventilator-associated pneumonia. Am J Respir Crit Care Med. 2010;182(7):870–6.CrossRefPubMed
65.
Verta A, Schena E, Silvestri S. Mathematical model and minimal measurement system for optimal control of heated humidifiers in neonatal ventilation. Med Eng Phys. 2010;32(5):475–81.CrossRefPubMed
66.
Kirkegaard L, Andersen BN, Jensen S. Moistening of inspired air during respirator treatment. Comparison between the water-bath evaporator and hygroscopic moisture heat exchanger. Ugeskr Laeger. 1987;149(3):152–5.PubMed
67.
Martin C, Perrin G, Gevaudan MJ, Saux P, Gouin F. Heat and moisture exchangers and vaporizing humidifiers in the intensive care unit. Chest. 1990;97(1):144–9.CrossRefPubMed
68.
Misset B, Escudier B, Rivara D, Leclercq B, Nitenberg G. Heat and moisture exchanger vs heated humidifier during long-term mechanical ventilation. A prospective randomized study. Chest. 1991;100(1):160–3.CrossRefPubMed
69.
Roustan JP, Kienlen J, Aubas P, Aubas S, du Cailar J. Comparison of hydrophobic heat and moisture exchangers with heated humidifier during prolonged mechanical ventilation. Intensive Care Med. 1992;18(2):97–100.CrossRefPubMed
70.
Dreyfuss D, Djedaini K, Gros I, Mier L, LeBourdelles G, Cohen Y, et al. Mechanical ventilation with heated humidifiers or heat and moisture exchangers: effects on patient colonization and incidence of nosocomial pneumonia. Am J Respir Crit Care Med. 1995;151(4):986–92.PubMed
71.
Branson RD, Davis Jr K, Brown R, Rashkin M. Comparison of three humidification techniques during mechanical ventilation: patient selection, cost and infections considerations. Respir Care. 1996;41(9):809–16.
72.
Villafane MC, Cinnella G, Lofaso F, Isabey D, Harf A, Lemaire F, et al. Gradual reduction of endotracheal tube diameter during mechanical ventilation via different humidification devices. Anesthesiology. 1996;85(6):1341–9.CrossRefPubMed
73.
Boots R, Howe S, George N, Harris F, Faoagali J. Clinical utility of hygroscopic heat and moisture exchangers in intensive care patients. Crit Care Med. 1997;25(10):1707–12.CrossRefPubMed
74.
Hurni J, Feihl F, Lazor R, Leuenberger P, Perret C. Safety of combined heat and moisture exchanger filters in long term mechanical ventilation. Chest. 1997;111(3):686–91.CrossRefPubMed
75.
Kirton O, De Haven B, Morgan J, Morejon O, Civetta J. A prospective, randomised comparison of an in-line heat moisture exchange filter and heated wire humidifiers: rates of ventilator-associated early-onset (community-acquired) or late-onset (hospital-acquired) pneumonia and incidence of endotracheal tube occlusion. Chest. 1997;112(4):1055–9.CrossRefPubMed
76.
Kollef MH, Shapiro SD, Boyd V, Silver P, Von Harz B, Trovillion E, et al. A randomized clinical trial comparing an extended-use hygroscopic condenser humidifier with heated-water humidification in mechanically ventilated patients. Chest. 1998;113(3):759–67.CrossRefPubMed
77.
Luchetti M, Stuani A, Castelli G, Marraro G. Comparison of three different humidification systems during prolonged mechanical ventilation. Minerva Anestesiol. 1998;64(3):75–81.PubMed
78.
Memish ZA, Oni GA, Djazmati W, Cunningham G, Mah MW. A randomized clinical trial to compare the effects of a heat and moisture exchanger with a heated humidifying system on the occurrence rate of ventilator-associated pneumonia. Am J Infect Control. 2001;29(5):301–5.CrossRefPubMed
79.
Diaz RB, Barbosa DA, Bettencourt AR, Vianna LAC, Gir E, Guimaraes T. Evalution [sic] the use of hygroscopic humidifier filters to prevent nosocomial pneumonia. Acta Paulista de Enfermagem. 2002;15(4):32–44.
80.
Lacherade JC, Auburtin M, Cerf C, Van de Louw A, Soufir L, Rebufat Y, et al. Impact of humidification systems on ventilator-associated pneumonia: a randomized multicenter trial. Am J Respir Crit Care Med. 2005;172(10):1276–82.CrossRefPubMed
81.
Lorente L, Lecuona M, Jimenez A, Mora ML, Sierra A. Ventilator-associated pneumonia using a heated humidifier or a heat and moisture exchanger: a randomized controlled trial. Crit Care. 2006;10(4):R116.CrossRefPubMedPubMedCentral
82.
Boots RJ, George N, Faoagali JL, Druery J, Dean K, Heller RF. Double-heater-wire circuits and heat-and-moisture exchangers and the risk of ventilator-associated pneumonia. Crit Care Med. 2006;34(3):687–93.CrossRefPubMed
83.
Oguz S, Deger I. Ventilator-associated pneumonia in patients using HME filters and heated humidifiers. Ir J Med Sci. 2013;182(4):651–5.CrossRefPubMed
84.
Bench S. Humifification in thr long-term ventilated patients; a systematic review. Intens Crit Care Nurs. 2033;19:75–84.CrossRef
85.
Hess DR, Kallstrom TJ, Mottram CD, et al. American Association for Respiratory Care are of the ventilator circuit and its relation to ventilator associated pneumonia. Respir Care. 2003;48:869–79.PubMed
86.
Kola A, Eckmanns T, Gaistmeier P. Efficacy of heat and moisturing exchangers in preventing ventilator-associated pneumonia: meta-analysis of randomized controlled trials. Intensive Care Med. 2005;31:5–11.CrossRefPubMed
87.
Siempos II, Vardakas KZ, Kopterides P, Falagas ME. Impact of passive humidifcation on clinical outcomes of mechanically ventilated patients: a meta-analysis of randomized controlled trials. Crit Care Med. 2007;35:2843–51.CrossRefPubMed
Metadata
Title
Heat and moisture exchangers (HMEs) and heated humidifiers (HHs) in adult critically ill patients: a systematic review, meta-analysis and meta-regression of randomized controlled trials
Authors
Maria Vargas
Davide Chiumello
Yuda Sutherasan
Lorenzo Ball
Antonio M. Esquinas
Paolo Pelosi
Giuseppe Servillo
Publication date
01-12-2017
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2017
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-017-1710-5

Other articles of this Issue 1/2017

Critical Care 1/2017 Go to the issue

Editorial

Rapid identification of antimicrobial resistance patterns allows a faster antibiotic adequacy

Research

Initial blood pH during cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients: a multicenter observational registry-based study

Letter

Relapsing fever in young refugees from East Africa

Editorial

Understanding fluid administration approaches in children with co-morbidities and septic shock

Letter

Dexmedetomidine as a promising prevention strategy for cardiac surgery-associated acute kidney injury: a meta-analysis

Research

Trials directly comparing alternative spontaneous breathing trial techniques: a systematic review and meta-analysis