Our study confirmed an association between higher driving pressure and higher mortality in mechanically ventilated patients with acute respiratory distress syndrome. These findings suggest a possible range of driving pressure to be evaluated in clinical trials. Future research is needed to ascertain the benefit of ventilatory strategies targeting driving pressure in patients with acute respiratory distress syndrome.

Key Points Question What is the relative association of management strategies for adult patients with moderate to severe acute respiratory distress syndrome with mortality and barotrauma? Findings In this systematic review and network meta-analysis of 25 randomized clinical trials including 7743 patients, venovenous extracorporeal membrane oxygenation and prone positioning were associated with significantly lower 28-day mortality compared with lung protective ventilation alone. Moreover, venovenous extracorporeal membrane oxygenation was the highest-ranked intervention associated with a reduction in 28-day mortality among the 9 interventions evaluated. Meaning These findings support the use of prone positioning in patients with moderate to severe acute respiratory distress syndrome and venovenous extracorporeal membrane oxygenation in patients with severe acute respiratory distress syndrome.

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BackgroundManagement of patients with acute respiratory distress syndrome (ARDS) remains supportive with lung protective mechanical ventilation. In this article, we discuss the physiological concept of driving pressure, current data, ongoing trials, and future directions needed to clarify the role of driving pressure in patients with ARDS.BodyDriving pressure is the plateau airway pressure minus PEEP. It can also be expressed as the ratio of tidal volume to respiratory system compliance, indicating the decreased functional size of the lung observed in patients with ARDS (i.e., baby lung). Driving pressure as a strong predictor of mortality in patients with ARDS is supported by a post hoc analysis of previous randomized controlled trials and a subsequent meta-analysis. Importantly, the meta-analysis suggested targeting driving pressure below 13–15 cmH2O. Ongoing clinical trials of driving pressure in patients with ARDS focus mainly on physiological rather than clinical outcome but will provide important insights for the design of future clinical trials.ConclusionCurrently, no definite clinical recommendations on the routine use of driving pressure in patients with ARDS can be made, as the available data are hypothesis-generating. Randomized controlled trials are needed to evaluate the efficacy of a driving pressure-based ventilation strategy.