• Martin Urner, Peter Jüni, L Paloma Rojas-Saunero, Bettina Hansen, Laurent J Brochard, Niall D Ferguson, and Eddy Fan.
• Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
• Crit. Care Med. 2023 Jul 1; 51 (7): 861871861-871.

ObjectivesPrevious studies reported an association between higher driving pressure (∆P) and increased mortality for different groups of mechanically ventilated patients. However, it remained unclear if sustained intervention on ∆P, in addition to traditional lung-protective ventilation, improves outcomes. We investigated if ventilation strategies limiting daily static or dynamic ∆P reduce mortality compared with usual care in adult patients requiring greater than or equal to 24 hours of mechanical ventilation.DesignFor this comparative effectiveness study, we emulated pragmatic clinical trials using data from the Toronto Intensive Care Observational Registry recorded between April 2014 and August 2021. The per-protocol effect of the interventions was estimated using the parametric g-formula, a method that controls for baseline and time-varying confounding, as well as for competing events in the analysis of longitudinal exposures.SettingNine ICUs from seven University of Toronto-affiliated hospitals.PatientsAdult patients (≥18 yr) requiring greater than or equal to 24 hours of mechanical ventilation.InterventionsReceipt of a ventilation strategy that limited either daily static or dynamic ∆P less than or equal to 15 cm H 2 O compared with usual care.Measurements And Main ResultsAmong the 12,865 eligible patients, 4,468 of (35%) were ventilated with dynamic ∆P greater than 15 cm H 2 O at baseline. Mortality under usual care was 20.1% (95% CI, 19.4-20.9%). Limiting daily dynamic ∆P less than or equal to 15 cm H 2 O in addition to traditional lung-protective ventilation reduced adherence-adjusted mortality to 18.1% (95% CI, 17.5-18.9%) (risk ratio, 0.90; 95% CI, 0.89-0.92). In further analyses, this effect was most pronounced for early and sustained interventions. Static ∆P at baseline were recorded in only 2,473 patients but similar effects were observed. Conversely, strict interventions on tidal volumes or peak inspiratory pressures, irrespective of ∆P, did not reduce mortality compared with usual care.ConclusionsLimiting either static or dynamic ∆P can further reduce the mortality of patients requiring mechanical ventilation.Copyright © 2023 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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