TY - JOUR
T1 - Higher PEEP for acute respiratory distress syndrome
T2 - A Bayesian meta-analysis of randomised clinical trials
AU - Neto, Ary Serpa
AU - Tomlinson, George
AU - Sahetya, Sarina K.
AU - Ball, Lorenzo
AU - Nichol, Alistair D.
AU - Hodgson, Carol
AU - Cavalcanti, Alexandre Biasi
AU - Briel, Matthias
AU - de Abreu, Marcelo Gama
AU - Pelosi, Paolo
AU - Schultz, Marcus J.
AU - Goligher, Ewan C.
N1 - Publisher Copyright:
© 2021, College of Intensive Care Medicine. All rights reserved.
PY - 2021/6
Y1 - 2021/6
N2 - Objective: Benefit or harm of higher positive end expiratory pressure (PEEP) for acute respiratory distress syndrome (ARDS) is controversial. We aimed to assess the impact of higher levels of PEEP in patients with ARDS under a Bayesian framework. Design: Systematic review and Bayesian meta-analysis of randomised clinical trials comparing higher to lower PEEP in adult patients with ARDS. Data sources: MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials from 1996 to 1 March 2020. Review methods: We extracted data from high quality randomised clinical trials comparing higher to lower levels of PEEP in adult patients, using low tidal volume in both arms, and conducted a Bayesian meta-analysis using aggregate data from these studies. Results: Eight clinical trials including 3703 patients (n = 1833 for higher PEEP, n = 1870 for lower PEEP) were included. Under a minimally informative prior, the posterior probability of benefit with higher PEEP was 65% (relative risk, 0.97 [95% credible interval, 0.78-1.14]). In patients with moderate-tosevere ARDS, the posterior probability of benefit with higher PEEP was 77% (relative risk, 0.94 [95% credible interval, 0.77-1.13]). Down-weighting studies that employed a maximum recruitment strategy by 100% increased the posterior probability of benefit to 92% under a minimally informative prior. Conclusions: The probability of benefit or harm from routine use of higher PEEP for patients with ARDS ranges from 27% to 86%, and from 14% to 73% depending on one’s prior, suggesting continued uncertainty and equipoise regarding the benefit of PEEP. If data from trials using a maximum recruitment strategy is discounted to some extent because of uncertainty over the appropriateness of this approach, the available evidence suggests that higher PEEP could be beneficial for moderate-to-severe ARDS. However, well powered randomized clinical trials are needed to confirm these findings.
AB - Objective: Benefit or harm of higher positive end expiratory pressure (PEEP) for acute respiratory distress syndrome (ARDS) is controversial. We aimed to assess the impact of higher levels of PEEP in patients with ARDS under a Bayesian framework. Design: Systematic review and Bayesian meta-analysis of randomised clinical trials comparing higher to lower PEEP in adult patients with ARDS. Data sources: MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials from 1996 to 1 March 2020. Review methods: We extracted data from high quality randomised clinical trials comparing higher to lower levels of PEEP in adult patients, using low tidal volume in both arms, and conducted a Bayesian meta-analysis using aggregate data from these studies. Results: Eight clinical trials including 3703 patients (n = 1833 for higher PEEP, n = 1870 for lower PEEP) were included. Under a minimally informative prior, the posterior probability of benefit with higher PEEP was 65% (relative risk, 0.97 [95% credible interval, 0.78-1.14]). In patients with moderate-tosevere ARDS, the posterior probability of benefit with higher PEEP was 77% (relative risk, 0.94 [95% credible interval, 0.77-1.13]). Down-weighting studies that employed a maximum recruitment strategy by 100% increased the posterior probability of benefit to 92% under a minimally informative prior. Conclusions: The probability of benefit or harm from routine use of higher PEEP for patients with ARDS ranges from 27% to 86%, and from 14% to 73% depending on one’s prior, suggesting continued uncertainty and equipoise regarding the benefit of PEEP. If data from trials using a maximum recruitment strategy is discounted to some extent because of uncertainty over the appropriateness of this approach, the available evidence suggests that higher PEEP could be beneficial for moderate-to-severe ARDS. However, well powered randomized clinical trials are needed to confirm these findings.
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U2 - 10.51893/2021.2.oa4
DO - 10.51893/2021.2.oa4
M3 - Article
AN - SCOPUS:85128445012
SN - 1441-2772
VL - 23
SP - 171
EP - 182
JO - Critical Care and Resuscitation
JF - Critical Care and Resuscitation
IS - 2
ER -