Higher vs. Lower DP for Ventilated Patients with Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis

Abstract

Objectives. Driving pressure (DP) has recently become a promising mediator for the identification of the effects of mechanical ventilation on outcomes in acute respiratory distress syndrome (ARDS). The aim of this study was to systematically and quantitatively update and assess the association between DP and mortality among ventilated patients with ARDS. Methods. PubMed, the Cochrane Library, ISI Web of Knowledge, and Embase were systematically searched from inception to June 2018. Two investigators conducted the literature search study selection, data extraction, and quality evaluation independently. RevMan 5.3 software was used for all statistical analyses. Results. A total of seven studies comprising 8010 patients were included in this meta-analysis. Higher DP showed a significant association with higher mortality (pooled risk ratio, 1.10; 95% [CI], 1.05–1.16; I2 =58%). Sensitivity analysis indicated that one study significantly affected the stability of pooled results. One of the subgroups investigated, ARDS severity, could account for the heterogeneity. An exploratory post hoc subgroup analysis and higher DP significantly increased mortality in the mild to severe ARDS subgroup (RR 1.28; 95% [CI], 1.14–1.43; I2 =0), but not in the moderate to severe ARDS subgroup (RR 1.18; 95% [CI], 0.95–1.46; I2 =52%). Conclusion. Higher DP was significantly associated with an increased risk of death among ventilated patients with ARDS. But it did not seem to predict prognosis to moderate to severe ARDS. Future prospective randomized clinical trials are needed to verify the results of this meta-analysis and address the unresolved questions about optimum cutoff values for DP. Trial Registration. This trial is registered with PROSPERO (CRD42018102146), on 11 August 2018.

Invasive Ventilatory Support in Patients With Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

“…Individual changes in V T or PEEP after randomization were not independently associated with survival, except if they were among changes leading to reductions in DP (mediation effects of DP, p = 0.004 and p = 0.001, respectively). Other meta-analyses (20, 21) in the adult ARDS population have demonstrated similar findings.…”

Maintenance of low driving pressure in patients with early acute respiratory distress syndrome significantly affects outcomes

“…In a secondary analysis study of multiple independent variables, decreases in ∆P were strongly associated with the increased survival of patients with ARDS [ 8 ]. Several studies that have focused on the use of ∆P to predict the mortality of patients with ARDS have revealed similar results [ 4 , 11 , 15 , 16 ]. ∆P during mechanical ventilation is significantly related to stress forces in the lung.…”

Unshrinking the baby lung to calm the VILI vortex

“…Appreciation of this fact is evidenced by the recent interest in driving pressure (ΔP), calculated as the difference between plateau and end-expiratory pressures. ΔP can evolve over a patient's clinical course and is approximated by the ratio V T /C RS , which explains why letting V T be influenced by C RS has proven to be better at stratifying ARDS-related mortality risk compared to weight-based V T [7,[11][12][13][14][15].…”

“…These observations beg the question as to whether ΔP should replace V T as the key factor guiding protective ventilation strategies [7,[11][12][13][14][15][16]. Dramatic reductions in ΔP can be achieved with high-frequency oscillatory ventilation (HFOV), because it uses V T that are less than the anatomic dead space volume.…”