Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome
Abstract
BACKGROUND: Most patients requiring mechanical ventilation for acute lung injury and the acute respiratory distress syndrome (ARDS) receive positive end-expiratory pressure (PEEP) of 5 to 12 cm of water. Higher PEEP levels may improve oxygenation and reduce ventilator-induced lung injury but may also cause circulatory depression and lung injury from overdistention. We conducted this trial to compare the effects of higher and lower PEEP levels on clinical outcomes in these patients. METHODS: We randomly assigned 549 patients with acute lung injury and ARDS to receive mechanical ventilation with either lower or higher PEEP levels, which were set according to different tables of predetermined combinations of PEEP and fraction of inspired oxygen. RESULTS: Mean (+/-SD) PEEP values on days 1 through 4 were 8.3+/-3.2 cm of water in the lower-PEEP group and 13.2+/-3.5 cm of water in the higher-PEEP group (P<0.001). The rates of death before hospital discharge were 24.9 percent and 27.5 percent, respectively (P=0.48; 95 percent confidence interval for the difference between groups, -10.0 to 4.7 percent). From day 1 to day 28, breathing was unassisted for a mean of 14.5+/-10.4 days in the lower-PEEP group and 13.8+/-10.6 days in the higher-PEEP group (P=0.50). CONCLUSIONS: 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.
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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 [439]
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 [439]
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- Authors
- The National Heart, L.
- Affiliations
- Johns Hopkins University (US)
- Corresponding author
- The National Heart, Lung, and Blood Institute ARDS Clinical Trials Network
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2004-07-22
- Volume
- 351
- Issue
- 4
- Pages
- 327-336
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2333411966
- Cited by
- 2,565
- References
- 38
- Citations by year
- 2026: 66 · 2025: 80 · 2024: 106 · 2023: 130 · 2022: 137 · 2021: 177 · 2020: 153 · 2019: 115 · 2018: 123 · 2017: 112 · 2016: 101 · 2015: 110 · 2014: 137 · 2013: 127 · 2012: 133
- FWCI
- 76.53
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (n01hr046061-006, n01hr046060-006, n01hr046063-006, n01hr046064-009, n01hr046056-006, n01hr046057-006, n01hr046062-006, n01hr046058-006, n01hr046055-006, n01hr046054-006, n01hr046059-006)
- National Heart, Lung, and Blood Institute (N01-HR-46059, N01-HR 46060, N01-HR-46054, N01-HR 46062, N01-HR-46063, N01-HR 46061, N01-HR-46057, N01-HR 46056, N01-HR46064, N01 HR46058, N0-1 HR 46055)
- 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
- acute respiratory distress syndrome, acute lung injury, positive end-expiratory pressure, mechanical ventilation, mortality, ventilator-induced lung injury, fraction of inspired oxygen, tidal volume, plateau pressure, weaning from mechanical ventilation
- MeSH terms
- Adult, Aged, Female, Humans, Male, Middle Aged, Positive-Pressure Respiration, Respiratory Distress Syndrome, Respiratory Physiological Phenomena, Biomarkers, Interleukin-6, Treatment Outcome, Hospital Mortality, Intercellular Adhesion Molecule-1, Pulmonary Surfactant-Associated Protein D
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