Association of Positive End-Expiratory Pressure and Lung Recruitment Selection Strategies with Mortality in Acute Respiratory Distress Syndrome A Systematic Review and Network Meta-analysis

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, Neill K.J. AdhikariFederico Angriman, Ewan C. Goligher

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23 Citations (Scopus)


Rationale: 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.

Original languageEnglish
Pages (from-to)1300-1310
Number of pages11
JournalAmerican Journal of Respiratory and Critical Care Medicine
Issue number11
Publication statusPublished - 1 Jun 2022


  • ARDS
  • hypoxemic respiratory failure
  • lung recruitment maneuver
  • mortality
  • PEEP

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