Positive End-Expiratory Pressure Setting in Adults With Acute Lung Injury and Acute Respiratory Distress Syndrome: A Randomized Controlled Trial
Abstract
CONTEXT: The need for lung protection is universally accepted, but the optimal level of positive end-expiratory pressure (PEEP) in patients with acute lung injury (ALI) or acute respiratory distress syndrome remains debated. OBJECTIVE: To compare the effect on outcome of a strategy for setting PEEP aimed at increasing alveolar recruitment while limiting hyperinflation to one aimed at minimizing alveolar distension in patients with ALI. DESIGN, SETTING, AND PATIENTS: A multicenter randomized controlled trial of 767 adults (mean [SD] age, 59.9 [15.4] years) with ALI conducted in 37 intensive care units in France from September 2002 to December 2005. INTERVENTION: Tidal volume was set at 6 mL/kg of predicted body weight in both strategies. Patients were randomly assigned to a moderate PEEP strategy (5-9 cm H(2)O) (minimal distension strategy; n = 382) or to a level of PEEP set to reach a plateau pressure of 28 to 30 cm H(2)O (increased recruitment strategy; n = 385). MAIN OUTCOME MEASURES: The primary end point was mortality at 28 days. Secondary end points were hospital mortality at 60 days, ventilator-free days, and organ failure-free days at 28 days. RESULTS: The 28-day mortality rate in the minimal distension group was 31.2% (n = 119) vs 27.8% (n = 107) in the increased recruitment group (relative risk, 1.12 [95% confidence interval, 0.90-1.40]; P = .31). The hospital mortality rate in the minimal distension group was 39.0% (n = 149) vs 35.4% (n = 136) in the increased recruitment group (relative risk, 1.10 [95% confidence interval, 0.92-1.32]; P = .30). The increased recruitment group compared with the minimal distension group had a higher median number of ventilator-free days (7 [interquartile range {IQR}, 0-19] vs 3 [IQR, 0-17]; P = .04) and organ failure-free days (6 [IQR, 0-18] vs 2 [IQR, 0-16]; P = .04). This strategy also was associated with higher compliance values, better oxygenation, less use of adjunctive therapies, and larger fluid requirements. CONCLUSIONS: A strategy for setting PEEP aimed at increasing alveolar recruitment while limiting hyperinflation did not significantly reduce mortality. However, it did improve lung function and reduced the duration of mechanical ventilation and the duration of organ failure. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00188058.
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A second option is to titrate PEEP upward while the patient is receiving a tidal volume of 6 mL/kg PBW, until the plateau airway pressure is 28 cm H2O.
“The second option is to titrate PEEP upward while the patient is receiving a tidal volume of 6 mL/kg PBW, until the plateau airway pressure is 28 cm H2O [441].”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [441]
A patient-level analysis of two of the randomised PEEP trials suggested that patients with ARDS who respond to increased PEEP with improved oxygenation have a lower risk of death; this association was stronger in patients with more severe ARDS (PaO2/FiO2 < 150 mmHg) compared with patients with less severe ARDS.
“A patient-level analysis of two of the randomised PEEP trials [440, 441] suggested that patients with ARDS who respond to increased PEEP with improved oxygenation have a lower risk of death; this association was stronger in patients with more severe ARDS (PaO2/FiO2 < 150 mmHg) compared with patients with less severe ARDS [444].”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [441]
We included three multicentre RCTs and one pilot RCT investigating use of higher PEEP versus lower PEEP strategies in conjunction with low tidal volumes for the management of patients with ARDS.
“We included three multicentre RCTs [439–441] and one pilot RCT [442], investigating use of higher PEEP versus lower PEEP strategies in conjunction with low tidal volumes for the management of patients with ARDS.”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [441]
A third option is to use a PEEP/FiO2 titration table that titrates PEEP based on the combination of FiO2 and PEEP required to maintain adequate oxygenation.
“A third option is to use a PEEP/FiO2 titration table that titrates PEEP based on the combination of FiO2 and PEEP required to maintain adequate oxygenation [439–441].”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [441]
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- Authors
- Mercat, A., Richard, J.-C. M., Vielle, B., Jaber, S., Osman, D., Diehl, J.-L., Lefrant, J.-Y., Prat, G., Richecoeur, J., Nieszkowska, A., Gervais, C., Baudot, J., Bouadma, L., Brochard, L., & Expiratory Pressure (Express) Study Group, F. T.
- Affiliations
- Centre Hospitalier Universitaire d'Angers (FR)
- Centre Hospitalier Universitaire de Rouen (FR)
- Chimie de la Matière Condensée de Paris (FR)
- Hôpital Bichat-Claude-Bernard (FR)
- Institut Mondor de Recherche Biomédicale (FR)
- ORCID
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2008-02-13
- Volume
- 299
- Issue
- 6
- Pages
- 646
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- OpenAlex
- W2109704422
- Cited by
- 1,344
- References
- 40
- Citations by year
- 2026: 38 · 2025: 42 · 2024: 58 · 2023: 51 · 2022: 67 · 2021: 94 · 2020: 75 · 2019: 76 · 2018: 74 · 2017: 86 · 2016: 67 · 2015: 79 · 2014: 87 · 2013: 88 · 2012: 86
- FWCI
- 83.55
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- JAMA (publishedVersion)
- PubMed (publishedVersion)
- HAL (submittedVersion)
- Topics
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Respiratory Support and Mechanisms
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Neonatal Respiratory Health Research
- Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Nosocomial Infections in ICU
- Keywords
- positive end-expiratory pressure, acute lung injury, acute respiratory distress syndrome, lung-protective ventilation, alveolar recruitment, plateau pressure, tidal volume, 28-day mortality, ventilator-free days, organ failure, mechanical ventilation, adults, intensive care unit patients, hyperinflation
- MeSH terms
- Aged, Female, Humans, Male, Middle Aged, Positive-Pressure Respiration, Respiratory Distress Syndrome, Tidal Volume, Ventilator Weaning, Survival Analysis, Hospital Mortality
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