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Caring for the Critically Ill Patient
March 3, 2010

Higher vs Lower Positive End-Expiratory Pressure in Patients With Acute Lung Injury and Acute Respiratory Distress Syndrome: Systematic Review and Meta-analysis

Author Affiliations

Author Affiliations: Departments of Clinical Epidemiology and Biostatistics (Drs Briel, Meade, Walter, Pullenayegum, Zhou, Cook, Lamontagne, and Guyatt and Ms Bhatnagar) and Medicine (Drs Meade and Guyatt), McMaster University, Hamilton, Ontario, Canada; Basel Institute for Clinical Epidemiology, University Hospital Basel, Basel, Switzerland (Dr Briel); University Hospital Angers, Angers, France (Dr Mercat); Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland (Dr Brower); Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts (Dr Talmor); University of Toronto, Toronto, Ontario, Canada (Drs Slutsky and Stewart); Medical ICU, University Hospital Albert Chenevier–Henri Mondor, INSERM Unit 955 and University Paris-Est, Créteil, France (Dr Brochard); University Hospital Charles Nicolle and UPRES EA Unit 3830, Rouen, France (Dr Richard); and University of Sherbrooke, Sherbrooke, Québec, Canada (Dr Lamontagne).

JAMA. 2010;303(9):865-873. doi:10.1001/jama.2010.218

Context Trials comparing higher vs lower levels of positive end-expiratory pressure (PEEP) in adults with acute lung injury or acute respiratory distress syndrome (ARDS) have been underpowered to detect small but potentially important effects on mortality or to explore subgroup differences.

Objectives To evaluate the association of higher vs lower PEEP with patient-important outcomes in adults with acute lung injury or ARDS who are receiving ventilation with low tidal volumes and to investigate whether these associations differ across prespecified subgroups.

Data Sources Search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (1996-January 2010) plus a hand search of conference proceedings (2004-January 2010).

Study Selection Two reviewers independently screened articles to identify studies randomly assigning adults with acute lung injury or ARDS to treatment with higher vs lower PEEP (with low tidal volume ventilation) and also reporting mortality.

Data Extraction Data from 2299 individual patients in 3 trials were analyzed using uniform outcome definitions. Prespecified effect modifiers were tested using multivariable hierarchical regression, adjusting for important prognostic factors and clustering effects.

Results There were 374 hospital deaths in 1136 patients (32.9%) assigned to treatment with higher PEEP and 409 hospital deaths in 1163 patients (35.2%) assigned to lower PEEP (adjusted relative risk [RR], 0.94; 95% confidence interval [CI], 0.86-1.04; P = .25). Treatment effects varied with the presence or absence of ARDS, defined by a value of 200 mm Hg or less for the ratio of partial pressure of oxygen to fraction of inspired oxygen concentration (P = .02 for interaction). In patients with ARDS (n = 1892), there were 324 hospital deaths (34.1%) in the higher PEEP group and 368 (39.1%) in the lower PEEP group (adjusted RR, 0.90; 95% CI, 0.81-1.00; P = .049); in patients without ARDS (n = 404), there were 50 hospital deaths (27.2%) in the higher PEEP group and 44 (19.4%) in the lower PEEP group (adjusted RR, 1.37; 95% CI, 0.98-1.92; P = .07). Rates of pneumothorax and vasopressor use were similar.

Conclusions Treatment with higher vs lower levels of PEEP was not associated with improved hospital survival. However, higher levels were associated with improved survival among the subgroup of patients with ARDS.