Effect of different levels of PEEP on mortality in ICU patients without acute respiratory distress syndrome: systematic review and meta-analysis with trial sequential analysis

Shuai Shao; Hanyujie Kang; Zhenbei Qian; Yingquan Wang; Zhaohui Tong

doi:10.1016/j.jcrc.2021.06.015

Effect of different levels of PEEP on mortality in ICU patients without acute respiratory distress syndrome: systematic review and meta-analysis with trial sequential analysis

J Crit Care. 2021 Oct:65:246-258. doi: 10.1016/j.jcrc.2021.06.015. Epub 2021 Jul 3.

Authors

Shuai Shao¹, Hanyujie Kang¹, Zhenbei Qian¹, Yingquan Wang¹, Zhaohui Tong²

Affiliations

¹ Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China.
² Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China. Electronic address: tongzhaohuicy@sina.com.

Abstract

Objective: To determine whether higher positive end- expiratory pressure (PEEP) could provide a survival advantage for patients without acute respiratory distress syndrome (ARDS) compared with lower PEEP.

Methods: Eligible studies were identified through searches of Embase, Cochrane Library, Web of Science, Medline, and Wanfang database from inception up to 1 June 2021. Trial sequential analysis (TSA) was used in this meta-analysis.

Data synthesis: Twenty-seven randomized controlled trials (RCTs) were identified for further evaluation. Higher and lower PEEP arms included 1330 patients and 1650 patients, respectively. A mean level of 9.6±3.4 cmH₂O was applied in the higher PEEP groups and 1.9±2.6 cmH₂O was used in the lower PEEP groups. Higher PEEP, compared with lower PEEP, was not associated with reduction of all-cause mortality (RR 1.03; 95% CI 0.91-1.18; P =0.627), and 28-day mortality (RR 1.07 ; 95% CI 0.92-1.24; P =0.365). In terms of risk of ARDS (RR 0.43; 95% CI 0.24-0.78; P =0.005), duration of intensive care unit (MD -1.04; 95%CI-1.36 to -0.73; P < 0.00001), and oxygenation (MD 40.30; 95%CI 0.94 to 79.65; P = 0.045), higher PEEP was superior to lower PEEP. Besides, the pooled analysis showed no significant differences between groups both in the duration of mechanical ventilation (MD 0.00; 95%CI-0.13 to 0.13; P = 0.996) and hospital stay (MD -0.66; 95%CI-1.94 to 0.61; P = 0.309). More importantly, lower PEEP did not increase the risk of pneumonia, atelectasis, barotrauma, hypoxemia, or hypotension among patients compared with higher PEEP. The TSA analysis showed that the results of all-cause mortality and 28-day mortality might be false-negative results.

Conclusions: Our results suggest that a lower PEEP ventilation strategy was non-inferior to a higher PEEP ventilation strategy in ICU patients without ARDS, with no increased risk of all-cause mortality and 28-day mortality. Further high-quality RCTs should be performed to confirm these findings.

Keywords: Intensive care unit; Mechanical ventilation; Meta-analysis; Mortality; Positive end-expiratory pressure.

Publication types

Meta-Analysis
Research Support, Non-U.S. Gov't
Review
Systematic Review

MeSH terms

Humans
Intensive Care Units
Length of Stay
Positive-Pressure Respiration
Respiration, Artificial
Respiratory Distress Syndrome* / therapy