- For patients with acute respiratory distress syndrome (ARDS), positive end-expiratory pressure (PEEP) titration guided by esophageal pressure (PES) offers no clear advantage over empirical high PEEP-FIO2.
- Editorial discusses differences in protocol, results vs EPVent and concludes: “for most patients with moderate to severe ARDS, the use of a simple and widely available tool to adjust PEEP will result in similar clinical outcomes to those of a more invasive, costly, and cumbersome strategy.”
Why this matters
- Benefit of PEEP optimization is unclear, and the process is difficult because it must not only improve oxygenation but also prevent ventilator-induced lung injury (VILI).
- Pleural pressure correlates with PES (measured by esophageal manometer).
- PES-guided PEEP appeared advantageous in 2008 EPVent trial.
- PES-guided vs empirical PEEP:
- Primary outcome: no significant difference.
- Death: no significant difference.
- Days free from mechanical ventilation: no significant difference.
- 14-hospital randomized clinical EPVent-2 (n=200).
- Patients aged ≥16 years with moderate to severe ARDS were randomly assigned to receive PES-guided PEEP vs empirical high PEEP-FIO2.
- Outcome: ranked composite score incorporating death and days free from mechanical ventilation among survivors through day 28.
- Funding: NIH.
- Underpowered for meaningful survival differences.
- Prone positioning prohibited except as rescue.