Searching for the Optimal PEEP in Patients Without ARDS

Sahetya, Sarina K.; Goligher, Ewan C.; Slutsky, Arthur S.

doi:10.1001/jama.2020.23067

Cited by 8 publications

(7 citation statements)

References 18 publications

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“…However, higher PEEP could improve the P/F ratio and duration of ICU stay. For several years, the main goal of PEEP was to improve patients' oxygenation and deliver oxygen [ 24 ]. But as time went on, this goal shifted to reduce VILI by limiting Vt and inspiratory pressure when sufficient PEEP was provided to avoid collapse of lung [ 3 ].…”

Section: Discussionmentioning

confidence: 99%

“…Meta-regression was performed using a random-effects model analysis to find the potential sources of heterogeneity. Meta-regression was performed by using the following covariates: publication year (<2000 year and ≥2000 year) [ 17 ], the proportion of males, mean age, race, including acute respiratory failure (ARF) patients or not [ 24 ]. The funnel plot and Egger's test were applied to reveal the outcome's publication bias, which included more than five studies [ 25 ].…”

Section: Methodsmentioning

confidence: 99%

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Effect of different levels of PEEP on mortality in ICU patients without acute respiratory distress syndrome: systematic review and meta-analysis with trial sequential analysis

Shao

Kang

Qian

et al. 2021

Journal of Critical Care

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Objective To determine whether higher positive end- expiratory pressure (PEEP) could provide a survival advantage for patients without acute respiratory distress syndrome (ARDS) compared with lower PEEP. Methods Eligible studies were identified through searches of Embase, Cochrane Library, Web of Science, Medline, and Wanfang database from inception up to 1 June 2021. Trial sequential analysis (TSA) was used in this meta-analysis. Data synthesis Twenty-seven randomized controlled trials (RCTs) were identified for further evaluation. Higher and lower PEEP arms included 1330 patients and 1650 patients, respectively. A mean level of 9.6±3.4 cmH 2 O was applied in the higher PEEP groups and 1.9±2.6 cmH 2 O was used in the lower PEEP groups. Higher PEEP, compared with lower PEEP, was not associated with reduction of all-cause mortality (RR 1.03; 95% CI 0.91–1.18; P =0.627), and 28-day mortality (RR 1.07 ; 95% CI 0.92–1.24; P =0.365). In terms of risk of ARDS (RR 0.43; 95% CI 0.24–0.78; P =0.005), duration of intensive care unit (MD -1.04; 95%CI-1.36 to −0.73; P < 0.00001), and oxygenation (MD 40.30; 95%CI 0.94 to 79.65; P = 0.045), higher PEEP was superior to lower PEEP. Besides, the pooled analysis showed no significant differences between groups both in the duration of mechanical ventilation (MD 0.00; 95%CI-0.13 to 0.13; P = 0.996) and hospital stay (MD -0.66; 95%CI-1.94 to 0.61; P = 0.309). More importantly, lower PEEP did not increase the risk of pneumonia, atelectasis, barotrauma, hypoxemia, or hypotension among patients compared with higher PEEP. The TSA analysis showed that the results of all-cause mortality and 28-day mortality might be false-negative results. Conclusions Our results suggest that a lower PEEP ventilation strategy was non-inferior to a higher PEEP ventilation strategy in ICU patients without ARDS, with no increased risk of all-cause mortality and 28-day mortality. Further high-quality RCTs should be performed to confirm these findings.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Effect of different levels of PEEP on mortality in ICU patients without acute respiratory distress syndrome: systematic review and meta-analysis with trial sequential analysis

Shao

Kang

Qian

et al. 2021

Journal of Critical Care

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“…Although our findings provide evidence of the potential benefits or harmful effects of different PEEP levels, PEEP should not just be applied according to its height, as many physiologic effects of PEEP could be U-shaped ( 44 , 45 ), Individualized PEEP regimes should be optimized based on a specific patient's physiology rather than focusing simply on the dosage. To date, however, no trial has attempted to evaluate the efficacy of PEEP in patients without ARDS prior to randomization ( 4 ), which necessitates future trials.…”

Section: Discussionmentioning

confidence: 99%

“…To date, however, the optimal PEEP levels remain unclear, owing to occurrence of potential negative effects that cause overdistention of the lungs, exacerbate lung stress as well as strain and impair hemodynamics by reducing venous return and increasing pulmonary vascular resistance. Therefore, PEEP's net benefits or harm are depended on the balance between alveolar recruitment and overdistension, and should be particularly beneficial in disease states with substantial alveolar collapse ( 4 ). Nevertheless, this trade-off is often difficult to achieve clinically.…”

Section: Introductionmentioning

confidence: 99%

Optimal Positive End Expiratory Pressure Levels in Ventilated Patients Without Acute Respiratory Distress Syndrome: A Bayesian Network Meta-Analysis and Systematic Review of Randomized Controlled Trials

et al. 2021

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Background: To find the optimal positive end expiratory pressure (PEEP) in mechanical ventilated patients without Acute Respiratory Distress Syndrome (ARDS), we conducted a Bayesian network meta-analysis and systematic review of randomized controlled trials (RCTs) comparing different level of PEEP based on a novel classification of PEEP level: ZEEP group (PEEP = 0 cm H2O); lower PEEP group (PEEP = 1–6 cm H2O); intermediate PEEP group (PEEP = 7–10 cm H2O); higher PEEP group (PEEP > 10 cm H2O).Result: Twenty eight eligible studies with 2,712 patients were included. There were no significant differences in the duration of mechanical ventilation between higher and intermediate PEEP (MD: 0.020, 95% CI: −0.14, 0.28), higher and lower PEEP (MD: −0.010, 95% CI: −0.23, 0.22), higher PEEP and ZEEP (MD: 0.010, 95% CI: −0.40, 0.22), intermediate and lower PEEP (MD: −0.040, 95% CI: −0.18, 0.040), intermediate PEEP and ZEEP (MD: −0.010, 95% CI: −0.42, 0.10), lower PEEP and ZEEP (MD: 0.020, 95% CI: −0.32, 0.13), respectively. Higher PEEP was associated with significantly higher PaO2/FiO2 ratio(PFR) when compared to ZEEP (MD: 73.24, 95% CI: 11.03, 130.7), and higher incidence of pneumothorax when compared to intermediate PEEP, lower PEEP and ZEEP (OR: 2.91e + 12, 95% CI: 40.3, 1.76e + 39; OR: 1.85e + 12, 95% CI: 29.2, 1.18e + 39; and OR: 1.44e + 12, 95% CI: 16.9, 8.70e + 38, respectively). There was no association between PEEP levels and other secondary outcomes.Conclusion: We identified higher PEEP was associated with significantly higher PFR and higher incidence of pneumothorax. Nonetheless, in terms of other outcomes, no significant differences were detected among four levels of PEEP.Systematic Review Registration: The study had registered on an international prospective register of systematic reviews, PROSPERO, on 09 April 2021, identifier: [CRD42021241745].

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“…First, there have been previous suggestions to use an applied PEEP of ≥ 10 cmH 2 O as an initial standardized ventilator setting for ARDS [ 4 – 7 ]. Second, a lower average PEEP of 5 to 8 cmH 2 O is more appropriate for non-ARDS surgical and cardiac patients [ 18 , 19 ]. Third, a regression line plotted for PEEP versus P/F ratio using our dataset intersected the P/F ratio of 150 mmHg (a value midway between 0 and 300 which has been shown to differentiate survivors versus non-survivors reasonably well [ 20 ]) at a PEEP of 10 cmH 2 O (Additional file 1 : Figure E2.).…”

Section: Methodsmentioning

confidence: 99%

P/FP ratio: incorporation of PEEP into the PaO2/FiO2 ratio for prognostication and classification of acute respiratory distress syndrome

Palanidurai

Phua

Chan

et al. 2021

Ann. Intensive Care

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Background The current Berlin definition of acute respiratory distress syndrome (ARDS) uses the PaO2/FiO2 (P/F) ratio to classify severity. However, for the same P/F ratio, a patient on a higher positive end-expiratory pressure (PEEP) may have more severe lung injury than one on a lower PEEP. Objectives We designed a new formula, the P/FP ratio, incorporating PEEP into the P/F ratio and multiplying with a correction factor of 10 [(PaO2*10)/(FiO2*PEEP)], to evaluate if it better predicts hospital mortality compared to the P/F ratio post-intubation and to assess the resultant changes in severity classification of ARDS. Methods We categorized patients from a dataset of seven ARDS network trials using the thresholds of ≤ 100 (severe), 101–200 (moderate), and 201–300 (mild) for both P/F (mmHg) and P/FP (mmHg/cmH2O) ratios and evaluated hospital mortality using areas under the receiver operating characteristic curves (AUC). Results Out of 3,442 patients, 1,057 (30.7%) died. The AUC for mortality was higher for the P/FP ratio than the P/F ratio for PEEP levels > 5 cmH2O: 0.710 (95% CI 0.691–0.730) versus 0.659 (95% CI 0.637–0.681), P < 0.001. Improved AUC was seen with increasing PEEP levels; for PEEP ≥ 18 cmH2O: 0.963 (95% CI 0.947–0.978) versus 0.828 (95% CI 0.765–0.891), P < 0.001. When the P/FP ratio was used instead of the P/F ratio, 12.5% and 15% of patients with moderate and mild ARDS, respectively, were moved to more severe categories, while 13.9% and 33.6% of patients with severe and moderate ARDS, respectively, were moved to milder categories. The median PEEP and FiO2 were 14 cmH2O and 0.70 for patients reclassified to severe ARDS, and 5 cmH2O and 0.40 for patients reclassified to mild ARDS. Conclusions The multifactorial P/FP ratio has a greater predictive validity for hospital mortality in ARDS than the P/F ratio. Changes in severity classification with the P/FP ratio reflect both true illness severity and the applied PEEP strategy. Trial registration: ClinialTrials.gov–NCT03946150.

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Searching for the Optimal PEEP in Patients Without ARDS

Cited by 8 publications

References 18 publications

Effect of different levels of PEEP on mortality in ICU patients without acute respiratory distress syndrome: systematic review and meta-analysis with trial sequential analysis

Effect of different levels of PEEP on mortality in ICU patients without acute respiratory distress syndrome: systematic review and meta-analysis with trial sequential analysis

Optimal Positive End Expiratory Pressure Levels in Ventilated Patients Without Acute Respiratory Distress Syndrome: A Bayesian Network Meta-Analysis and Systematic Review of Randomized Controlled Trials

P/FP ratio: incorporation of PEEP into the PaO2/FiO2 ratio for prognostication and classification of acute respiratory distress syndrome

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