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

Abstract

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.

Epidemiological profile and risk factors associated with death in patients receiving invasive mechanical ventilation in an adult intensive care unit from Brazil: a retrospective study

“…Concomitantly, we observed a higher survival rate in patients that used PEEP ≤8 cmH 2 O. However, the outcome does not seem to be associated with the PEEP cut-off point in the literature (22,23). Gatinoni and co-workers (2015) concluded that there is not "a PEEP correct value" and that it must be titrated by taking into consideration several factors (e.g., oxygenation and hemodynamics) (19).…”

“…However, when health professionals applied this value to normal lungs, there was no description of improvement in the outcome or time of hospital stay in the scientific literature yet ( 20 , 22 ). Therefore, according to individual ventilatory mechanics, we must make the best PEEP choice ( 23 ). At the same time, PaO 2 characterizes the degree of hypoxemia and hyperoxemia ( 24 ).…”

Standard vs. carbone dioxide adapted kidney replacement therapy in hypercapnic ARDS patients: a randomized controlled pilot trial (BigBIC)

“…This may in part be explained by the lower tidal volumes and lower respiratory minute volume in the intervention group, marking lung protective ventilation. Maintaining pH in a certain level is a common motivation to increase intensity of ventilation, and low bicarbonate has been identified as one factor leading to violation of lung-protective ventilation strategies [ 18 ].…”

Quality of Life and Family Support in Critically Ill Patients following ICU Discharge

“…Similar to the 6MWT distance, patients’ lung function presented significant improvement over 12 months in our study. Previous investigations showed that patients with ARDS presented mild abnormalities in lung spirometry following the ICU [ 32 , 33 , 34 ] or they may have presented fluctuations that were within the normal limits during 3 to 5 years of follow-up.…”