Does a Higher Positive End Expiratory Pressure Decrease Mortality in Acute Respiratory Distress Syndrome?

Phoenix, Susan I.; Paravastu, Sharath; Columb, Malachy O.; Vincent, Jean‐Louis; Nirmalan, Mahesh

doi:10.1097/aln.0b013e31819fae06

Cited by 97 publications

(62 citation statements)

References 22 publications

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“…Our study differs from prior meta-analyses 19,20,33 in several ways. First, our study includes the most recently published randomized controlled trial.…”

Section: Discussionmentioning

confidence: 62%

“…Third, we performed a sensitivity analysis with adjusted data from the 2 studies in which those data were available. 15,16 In contrast, 2 prior meta-analyses 19,20 pooled adjusted hospital mortality from one study 15 (where adjusted mortality favored higher PEEP), but did not include adjusted data from another trial that had imbalances in baseline characteristics 16 (adjusted data less favorable to higher PEEP). These 2 meta-analyses consequently reported an effect of higher PEEP on hospital mortality as a pooled odds ratio of 0.86 (95% CI 0.72-1.02) 20 and a pooled RR of 0.90 (95% CI 0.81-1.01).…”

Section: Discussionmentioning

confidence: 99%

“…14 The potential benefits of higher PEEP in patients with ALI/ARDS already receiving volume-limited or pressurelimited ventilation remain unclear, as existing randomized controlled trials may have been underpowered to find a potentially small but clinically important reduction in shortterm mortality. [15][16][17][18] Two study-level meta-analyses have been performed 19,20 : one concluded that higher PEEP was beneficial in unselected patients with ALI/ARDS. 19 However, that study's methods were suboptimal 21 because those researchers pooled adjusted hospital mortality from one of the studies 15 but did not include the adjusted hospital mortality data from another trial, in which there were also imbalances in baseline characteristics.…”

Section: Introductionmentioning

confidence: 99%

“…[15][16][17][18] Two study-level meta-analyses have been performed 19,20 : one concluded that higher PEEP was beneficial in unselected patients with ALI/ARDS. 19 However, that study's methods were suboptimal 21 because those researchers pooled adjusted hospital mortality from one of the studies 15 but did not include the adjusted hospital mortality data from another trial, in which there were also imbalances in baseline characteristics. 16 Our objective was to evaluate the benefits and harms of higher versus lower PEEP in adults with ALI/ARDS receiving volume-limited or pressure-limited ventilation, via meta-analysis of relevant randomized controlled trials that evaluated short-term unadjusted mortality and barotrauma.…”

Section: Introductionmentioning

confidence: 99%

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Higher PEEP in Patients With Acute Lung Injury: A Systematic Review and Meta-Analysis

2011

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BACKGROUND: Studies of ventilation strategies that included higher PEEP in patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) have yielded conflicting results. OBJECTIVE: To determine whether higher PEEP during volume-limited and pressure-limited ventilation is associated with 28-day mortality or barotrauma rates in patients with ALI/ARDS. METHODS: We searched MEDLINE, CENTRAL, EMBASE, CINAHL, Web of Science, and the bibliographies of retrieved papers to identify randomized controlled trials that compared higher and lower PEEP in adult patients with ALI/ARDS who were already receiving volume-limited or pressure-limited ventilation. Two of us independently abstracted study-level data, including study design, patient characteristics, study methods, intervention, and main results. We pooled the studylevel data with a random-effects model, unless heterogeneity was low (I 2 < 50%), in which case we used a fixed-effects model. The primary outcome was 28-day mortality. RESULTS: Four randomized trials (2,360 participants) were evaluated. Higher PEEP had a nonsignificant trend toward lower 28-day mortality (pooled relative risk 0.90, 95% CI 0.79 -1.02). There was no difference in barotrauma between the 2 groups (pooled relative risk 1.17, 95% CI 0.90 -1.52). Two studies reported an adjusted hospital death rate, and the pooled results of sensitivity analysis with those adjusted rates were identical to those of the unadjusted analysis. CONCLUSIONS: In 4 recent studies that used volume-limited or pressure-limited ventilation in ALI/ARDS patients, higher PEEP was not associated with significantly different short-term mortality or barotrauma. This study does not support the routine use of higher PEEP in patients with ALI/ARDS.

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“…Our study differs from prior meta-analyses 19,20,33 in several ways. First, our study includes the most recently published randomized controlled trial.…”

Section: Discussionmentioning

confidence: 62%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Higher PEEP in Patients With Acute Lung Injury: A Systematic Review and Meta-Analysis

2011

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“…4 Even with arbitrary setting of high or low PEEP, a recent metaanalysis suggested a 4% mortality benefit from high PEEP alone with ARDS patients. 5 Smaller studies have set PEEP according to lung mechanics and found improved and sustained oxygenation, but the studies were not large enough to identify an improvement in clinical outcomes. [6][7][8] In a recent randomized controlled trial, patients were allocated to receive mechanical ventilation either according to the ARDS Network protocol or guided by pleural pressure measured with esophageal balloon manometry.…”

Section: Introductionmentioning

confidence: 99%

Optimal PEEP Guided by Esophageal Balloon Manometry

Piraino

Cook

2011

Respir Care

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A 45-year-old female was admitted to our ICU with severe ascites, and septic shock due to an obstructive ureteric stone. Despite an F IO 2 of 1.0, high PEEP, and multiple recruitment maneuvers, it was challenging to obtain an S pO 2 > 85% after the patient was turned. We inserted an esophageal balloon to determine whether the abdominal pressure was affecting lung compliance. PEEP was guided to a level of 32 cm H 2 O to achieve a transpulmonary pressure of 0 cm H 2 O. Within 6 hours there was significant oxygenation improvement: P aO 2 /F IO 2 increased from 80 mm Hg to 244 mm Hg, and oxygenation index decreased from 35 to 18. At 48 hours, P aO 2 /F IO 2 was 382 mm Hg and oxygenation index was 7. Paracentesis of approximately 5 L assisted with weaning. Subsequent PEEP changes were guided by transpulmonary pressure. She was weaned from mechanical ventilation within 10 days, with no adverse sequelae associated with very high PEEP.

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Higher vs Lower Positive End-Expiratory Pressure in Patients With Acute Lung Injury and Acute Respiratory Distress Syndrome

Briel¹,

Meade²,

Mercat³

et al. 2010

JAMA

1,286

773

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ROTECTING LUNGS FROM VENTIlation-induced injury is an important principle in the management of patients with acute lung injury or acute respiratory distress syndrome (ARDS). Although the critical care community has generally endorsed lower tidal volumes and inspiratory pressures, the optimal level of positive end-expiratory pressure (PEEP) remains unestablished. 1,2 Experimental data suggest that PEEP levels exceeding traditional values of 5 to 12 cm H 2 O can minimize cyclical alveolar collapse and corresponding shearing injury to the lungs in patients with considerable edema and alveolar collapse. 3-5 For patients with relatively mild acute lung injury , however, potential adverse consequences of higher PEEP levels, including circulatory depression 6 or lung overdistension, 7 may outweigh the benefits. Several multicenter, randomized trials testing the incremental effect of higher levels See also p 883 and Patient Page.

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Does a Higher Positive End Expiratory Pressure Decrease Mortality in Acute Respiratory Distress Syndrome?

Cited by 97 publications

References 22 publications

Higher PEEP in Patients With Acute Lung Injury: A Systematic Review and Meta-Analysis

Higher PEEP in Patients With Acute Lung Injury: A Systematic Review and Meta-Analysis

Optimal PEEP Guided by Esophageal Balloon Manometry

Higher vs Lower Positive End-Expiratory Pressure in Patients With Acute Lung Injury and Acute Respiratory Distress Syndrome

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