ARDS · PEEP strategy
Higher versus lower positive end-expiratory pressures in patients with ARDS
| Design | Randomised controlled trial |
|---|---|
| Treatment | Higher PEEP strategy |
| Control | Lower PEEP strategy |
| Population | 549 patients with acute lung injury and ARDS, all ventilated at 6 mL/kg predicted body weight with plateau pressure limited to 30 cmH2O |
| Follow-up | Hospital discharge |
| Primary endpoint | Death before hospital discharge |
| Result | Mean PEEP over days 1 to 4 was 8.3±3.2 cmH2O in the lower-PEEP group and 13.2±3.5 in the higher-PEEP group (p<0.001). Death before discharge occurred in 24.9% and 27.5% respectively (p=0.48, 95% CI for the difference -10.0 to 4.7 percentage points). |
| Secondary endpoints | Ventilator-free days, organ failure-free days, barotrauma |
These results suggest that in patients with acute lung injury and ARDS who receive mechanical ventilation with a tidal-volume goal of 6 ml per kilogram of predicted body weight and an end-inspiratory plateau-pressure limit of 30 cm of water, clinical outcomes are similar whether lower or higher PEEP levels are used.
The trial authors, in the published abstract
The first of three concordant PEEP trials, with LOVS and ExPress. All neutral for mortality; all suggesting the benefit, if any, sits in severe ARDS. ART later showed that pushing recruitment harder causes outright harm.
Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 2004 Jul 22;351(4):327-36.