Is positive end-expiratory pressure (PEEP) more effective at higher levels or lower levels in mechanical ventilation?

Updated: Sep 15, 2020
  • Author: Christopher D Jackson, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Because trials comparing higher versus lower levels of PEEP in adults with acute lung injury or acute respiratory distress syndrome (ARDS) have been underpowered to detect small but potentially important effects on mortality or to explore subgroup differences, Briel et al performed a systematic review and meta-analysis of data from 2299 patients in 3 trials. Treatment with higher versus lower levels of PEEP was not associated with improved hospital survival: 374 hospital deaths occurred in 1136 patients (32.9%) assigned to treatment with higher PEEP, and 409 hospital deaths occurred in 1163 patients (35.2%) assigned to lower PEEP (adjusted relative risk [RR], 0.94; 95% confidence interval [CI], 0.86-1.04; P = .25). However, in the subgroup of patients with ARDS, higher levels were associated with improved survival: 324 hospital deaths (34.1%) occurred in the higher PEEP group and 368 (39.1%) occurred in the lower PEEP group (adjusted RR, 0.90; 95% CI, 0.81-1.00; P = .049). [4]

Because PEEP basically resets the baseline of the pressure-volume curve, the peak and plateau pressures will be affected. The clinician should pay close attention to the status of these pressure measurements (see image below).

Determination of the lower inflection point to est Determination of the lower inflection point to estimate the best (optimal) positive end-expiratory pressure (PEEP) from the pressure-volume hysteresis curve.

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