High levels of PEEP may improve survival in acute respiratory distress syndrome: A meta-analysis

Oba, Yuichi; Thameem, Danish; Zaza, Tareq

doi:10.1016/j.rmed.2009.02.008

Cited by 52 publications

(57 citation statements)

References 34 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: 66%

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: 66%

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

2011

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“…The aim of such a strategy is to prevent ventilator-induced lung injury by reversing lung collapse and hence avoiding cyclic tidal recruitment and to minimize lung overdistention by limiting the inspiratory driving pressure above the set openlung PEEP. [7][8][9][10][11] These slow stepwise increments in PIP, keeping inspiratory driving pressure Ͻ15 cm H 2 O, have less hemodynamic impact, particularly in children, and help to set the optimal PEEP. Other types of recruitment maneuvers frequently used in the operating theater are CPAP of 40 cm H 2 O for 8 -40 s or a few breaths at a high rate and high pressure (PIP ϭ 50 cm H 2 O/PEEP ϭ 5 cm H 2 O).…”

Section: See the Related Editorial On Page 260mentioning

confidence: 99%

“…16,17 Barotrauma is one of the major clinical concerns, especially in neonates and infants, due to their infinite thorax compliance, which makes them particularly sensitive to increases in airway pressure and prone to pneumothorax. 18,19 Most studies regarding recruitment maneuvers have been conducted in adult lungs with ARDS, 1,10,11,20 and information regarding the response to recruitment maneuvers in either healthy or sick pediatric patients is scarce.…”

Section: See the Related Editorial On Page 260mentioning

confidence: 99%

Neonatal Pneumothorax Pressures Surpass Higher Threshold in Lung Recruitment Maneuvers: An In Vivo Interventional Study

et al. 2015

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BACKGROUND: Causing pneumothorax is one of the main concerns of lung recruitment maneuvers in pediatric patients, especially newborns. Therefore, these maneuvers are not performed routinely during anesthesia. Our objective was to determine the pressures that cause pneumothorax in healthy newborns by a prospective experimental study of 10 newborn piglets (<48 h old) with healthy lungs under general anesthesia. METHODS: The primary outcome was peak inspiratory pressure (PIP) causing pneumothorax. Animals under anesthesia and bilateral chest tube catheterization were randomly allocated to 2 groups: one with PEEP and fixed inspiratory driving pressure of 15 cm H 2 O (PEEP group) and the second one with PEEP ‫؍‬ 0 cm H 2 O and non-fixed inspiratory driving pressure (zero PEEP group). In both groups, the ventilation mode was pressurecontrolled, and PIP was raised at 2-min intervals, with steps

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“…When Vt is considered, barotrauma was similar between Vt = 6 mL kg -1 and 12 mL kg -1 groups. In meta-analyses, high PEEP did not lead to an increased incidence of barotrauma (168,169). A reduction of barotrauma was observed when low Vt + high PEEP as opposed to high Vt + high PEEP [170].…”

Section: Pathophysiology: Evolution Of the Ideas Regarding Ardsmentioning

confidence: 87%

“…Accordingly, in early mild diffuse ARDS, Grasso observes that increasing PEEP lowers driving pressure [92]. A meta-analysis [169] confirms that the higher the predicted mortality, the greater the mortality reduction associated with high PEEP: the sicker the patients, the higher the PEEP should be viii) Recently, transpulmonary pressure was estimated without the use of an esophageal catheter [133]. This last method awaits independent validation.…”

Section: A Peep Peep [4[ (mentioning

confidence: 98%

Early severe acute respiratory distress syndrome: What’s going on? Part I: pathophysiology

Petitjeans

Pichot²,

Ghignone

et al. 2016

Anaesthesiol Intensive Ther

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Severe acute respiratory distress syndrome (ARDS, PaO 2 /FiO 2 < 100 on PEEP ≥ 5 cm H 2 O) is treated using controlled mechanical ventilation (CMV), recently combined with muscle relaxation for 48 h and prone positioning. While the amplitude of tidal volume appears set £ 6 mL kg -1 , the level of positive end-expiratory pressure (PEEP) remains controversial. This overview summarizes several salient points, namely: a) ARDS is an oxygenation defect: consolidation/difuse alveolar damage is reversed by PEEP and/or prone positioning, at least during the early phase of ARDS b) ARDS is a dynamic disease and partially iatrogenic. This implies that the management of the ventilator may be a life-saver by reducing the duration of mechanical ventilation, or detrimental by extending this duration, leading into critical care-acquired diseases. Indeed, a high PEEP (10−24 cm H 2 O) appears to be a life-saver in the context of early severe diffuse ARDS; c) tidal volume and plateau pressure cannot be identical for all patients; d) the only remaining rationale for CMV and muscle relaxation is to suppress patient-ventilator asynchrony and to lower VO 2 , during the acute cardio-ventilatory distress. Therefore, in early severe diffuse ARDS, this review argues for a combination of a high PEEP (preferably titrated on transpulmonary pressure) with spontaneous ventilation + pressure support (or newer modes of ventilation). However, conditionalities are stringent: upfront circulatory optimization, upright positioning, lowered VO 2 , lowered acidotic and hypercapnic drives, sedation without ventilatory depression and without lowered muscular tone. As these propositions require evidence-based demonstration, the accepted practice remains, in 2016, controlled mechanical ventilation, muscle relaxation, and prone position.

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High levels of PEEP may improve survival in acute respiratory distress syndrome: A meta-analysis

Abstract: The statistical and clinical heterogeneities make proper interpretation of the results difficult. However, a small, but significant mortality benefit of high PEEP may exist. In addition, our analysis suggests the effects of high PEEP are greater in patients with higher ICU severity scores.

Cited by 52 publications

References 34 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

Neonatal Pneumothorax Pressures Surpass Higher Threshold in Lung Recruitment Maneuvers: An In Vivo Interventional Study

Early severe acute respiratory distress syndrome: What’s going on? Part I: pathophysiology

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