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

Abstract

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.

Extracorporeal Life Support for Acute Respiratory Failure. A Systematic Review and Metaanalysis

“…Currently, lung-protective pressureand volume-limited ventilatory strategies aimed at mitigating ventilator-associated lung injury have become the standard of care (2). Clinical trials evaluating the use of higher positive end-expiratory pressure, recruitment maneuvers, high-frequency oscillatory ventilation, and prone positioning to further optimize lung protection in patients with ARDS have yielded variable results (4)(5)(6)(7)(8)(9)(10)(11).…”

Beyond Low Tidal Volumes

“…Several study-level 45,46 and individual patient data meta-analyses 47 have further evaluated the association between higher PEEP strategies and mortality. Although all included ALVEOLI, ExPress, and LOV, 1 meta-analysis 45 included a fourth study that used esophageal pressure measurements to ensure a positive end-expiratory transpulmonary pressure in the experimental group.…”

Respiratory Care Year in Review 2011: Long-Term Oxygen Therapy, Pulmonary Rehabilitation, Airway Management, Acute Lung Injury, Education, and Management

“…To help answer this question a studylevel meta-analysis of 4 randomized trials was reported in 2011. 69 Four previous meta-analyses have assessed similar questions. 70 -73 Like these prior meta-analyses, this study included the same 3 large multicenter randomized controlled trials, 58,74,75 but this is the first meta-analysis to include the recent single-center study using esophageal manometry to set PEEP.…”