• Jose Dianti, Manuel Tisminetzky, Bruno L Ferreyro, Marina Englesakis, Lorenzo Del Sorbo, Sachin Sud, Daniel Talmor, Lorenzo Ball, Maureen Meade, Carol Hodgson, Jeremy R Beitler, Sarina Sahetya, Alistair Nichol, Eddy Fan, Bram Rochwerg, Laurent Brochard, Arthur S Slutsky, Niall D Ferguson, Ary Serpa Neto, AdhikariNeill K JNKJ0000-0003-4038-5382Interdepartmental Division of Critical Care Medicine.Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health.Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, , Federico Angriman, and Ewan C Goligher.
• University Health Network/Sinai Health System.
• Am. J. Respir. Crit. Care Med. 2022 Jun 1; 205 (11): 1300-1310.

AbstractRationale: The most beneficial positive end-expiratory pressure (PEEP) selection strategy in patients with acute respiratory distress syndrome (ARDS) is unknown, and current practice is variable. Objectives: To compare the relative effects of different PEEP selection strategies on mortality in adults with moderate to severe ARDS. Methods: We conducted a network meta-analysis using a Bayesian framework. Certainty of evidence was evaluated using grading of recommendations assessment, development and evaluation methodology. Measurements and Main Results: We included 18 randomized trials (4,646 participants). Compared with a lower PEEP strategy, the posterior probability of mortality benefit from a higher PEEP without lung recruitment maneuver (LRM) strategy was 99% (risk ratio [RR], 0.77; 95% credible interval [CrI], 0.60-0.96, high certainty), the posterior probability of benefit of the esophageal pressure-guided strategy was 87% (RR, 0.77; 95% CrI, 0.48-1.22, moderate certainty), the posterior probability of benefit of a higher PEEP with brief LRM strategy was 96% (RR, 0.83; 95% CrI, 0.67-1.02, moderate certainty), and the posterior probability of increased mortality from a higher PEEP with prolonged LRM strategy was 77% (RR, 1.06; 95% CrI, 0.89-1.22, low certainty). Compared with a higher PEEP without LRM strategy, the posterior probability of increased mortality from a higher PEEP with prolonged LRM strategy was 99% (RR, 1.37; 95% CrI, 1.04-1.81, moderate certainty). Conclusions: In patients with moderate to severe ARDS, higher PEEP without LRM is associated with a lower risk of death than lower PEEP. A higher PEEP with prolonged LRM strategy is associated with increased risk of death when compared with higher PEEP without LRM.

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