Adjusting PEEP Not Effective in Acute Respiratory Distress Syndrome

Patients with acute respiratory distress syndrome (ARDS) who received positive end-expiratory pressure (PEEP) titration guided by esophageal pressure (P_ES) had no significant differences in outcome, according to study results published in the Journal of the American Medical Association.

Clinical outcomes were recorded in patients who received mechanical ventilation (age ≥16 years) with moderate to severe ARDS. Participants were randomly assigned to either P_ES-guided PEEP titration or to empirical high PEEP-fraction of inspired oxygen (FIO₂) in the phase 2 study of Mechanical Ventilation Directed by Transpulmonary Pressures (EPVent2; ClinicalTrials.gov Identifier: NCT01681225). The primary outcome of ranked composite score incorporating death and days free from mechanical ventilation in survivors through day 28 and secondary outcomes of 28-day mortality, days free from mechanical ventilation in survivors, and the need for rescue therapy were compared between groups.

A total of 200 participants were enrolled in the study and completed the 28-day follow-up. The mean age was 56 and 46% of the participants were women. By day 28, 33 of 102 patients (32.4%) assigned to P_ES-guided PEEP and 30 of 98 patients (30.6%) assigned to empirical PEEP-FIO₂ died. In the primary study outcome, ranked composite score incorporating death and days free from mechanical ventilation in survivors through day 28 was not significantly different between the treatment groups. Furthermore, days free from mechanical ventilation in survivors was not significantly different between the groups.

The researchers concluded that their findings do not support P_ES-guided PEEP titration in patients with ARDS.

Reference

Beitler JR, Sarge T, Banner-Goodspeed VM, et al; for the EPVent-2 Study Group. Effect of titrating positive end-expiratory pressure (PEEP) with an esophageal pressure–guided strategy vs an empirical high PEEP-FIO₂ strategy on death and days free from mechanical ventilation among patients with acute respiratory distress syndrome a randomized clinical trial [published February 18, 2019]. JAMA. doi:10.1001/jama.2019.0555