Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome

Systematic review and meta-analysis

Matthias Briel, Maureen Meade, Alain Mercat, Roy G Brower, Daniel Talmor, Stephen D. Walter, Arthur S. Slutsky, Eleanor Pullenayegum, Qi Zhou, Deborah Cook, Laurent Brochard, Jean Christophe M Richard, Francois Lamontagne, Neera Bhatnagar, Thomas E. Stewart, Gordon Guyatt

Research output: Contribution to journalArticle

Abstract

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.

Original languageEnglish (US)
Pages (from-to)865-873
Number of pages9
JournalJournal of the American Medical Association
Volume303
Issue number9
DOIs
StatePublished - Mar 3 2010

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Positive-Pressure Respiration
Acute Lung Injury
Adult Respiratory Distress Syndrome
Meta-Analysis
Tidal Volume
Confidence Intervals
Oxygen
Survival
Mortality
Partial Pressure
Information Storage and Retrieval
Pneumothorax
Therapeutics
MEDLINE
Cluster Analysis
Ventilation

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome : Systematic review and meta-analysis. / Briel, Matthias; Meade, Maureen; Mercat, Alain; Brower, Roy G; Talmor, Daniel; Walter, Stephen D.; Slutsky, Arthur S.; Pullenayegum, Eleanor; Zhou, Qi; Cook, Deborah; Brochard, Laurent; Richard, Jean Christophe M; Lamontagne, Francois; Bhatnagar, Neera; Stewart, Thomas E.; Guyatt, Gordon.

In: Journal of the American Medical Association, Vol. 303, No. 9, 03.03.2010, p. 865-873.

Research output: Contribution to journalArticle

Briel, M, Meade, M, Mercat, A, Brower, RG, Talmor, D, Walter, SD, Slutsky, AS, Pullenayegum, E, Zhou, Q, Cook, D, Brochard, L, Richard, JCM, Lamontagne, F, Bhatnagar, N, Stewart, TE & Guyatt, G 2010, 'Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: Systematic review and meta-analysis', Journal of the American Medical Association, vol. 303, no. 9, pp. 865-873. https://doi.org/10.1001/jama.2010.218
Briel, Matthias ; Meade, Maureen ; Mercat, Alain ; Brower, Roy G ; Talmor, Daniel ; Walter, Stephen D. ; Slutsky, Arthur S. ; Pullenayegum, Eleanor ; Zhou, Qi ; Cook, Deborah ; Brochard, Laurent ; Richard, Jean Christophe M ; Lamontagne, Francois ; Bhatnagar, Neera ; Stewart, Thomas E. ; Guyatt, Gordon. / Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome : Systematic review and meta-analysis. In: Journal of the American Medical Association. 2010 ; Vol. 303, No. 9. pp. 865-873.
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abstract = "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.",
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T1 - Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome

T2 - Systematic review and meta-analysis

AU - Briel, Matthias

AU - Meade, Maureen

AU - Mercat, Alain

AU - Brower, Roy G

AU - Talmor, Daniel

AU - Walter, Stephen D.

AU - Slutsky, Arthur S.

AU - Pullenayegum, Eleanor

AU - Zhou, Qi

AU - Cook, Deborah

AU - Brochard, Laurent

AU - Richard, Jean Christophe M

AU - Lamontagne, Francois

AU - Bhatnagar, Neera

AU - Stewart, Thomas E.

AU - Guyatt, Gordon

PY - 2010/3/3

Y1 - 2010/3/3

N2 - 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.

AB - 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.

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