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

Beitler JR, Sarge T, Banner-Goodspeed VM, et al. JAMA. 2019 Feb 18. [Epub ahead of print] [CrossRef] [PubMed]

Shortly after ARDS was described the beneficial effects of PEEP on oxygenation were discovered. However, PEEP can have deleterious effects.  Despite many proposed measures and methods, how to adjust the pressure to the “optimal” level has remained elusive. This multicenter study sought to determine whether PEEP titration guided by esophageal pressure (PES), an estimate of pleural pressure, was more effective than empirical high PEEP-fraction of inspired oxygen (Fio2) in moderate to severe ARDS. Two hundred mechanically ventilated patients aged 16 years and older with moderate to severe ARDS (Pao2:Fio2 ≤200 mm Hg) were randomized to PES-guided PEEP (n = 102) or empirical high PEEP-Fio2 (n = 98). All participants received low tidal volumes. PES-guided PEEP, compared with empirical high PEEP-Fio2, resulted in no significant difference in death and days free from mechanical ventilation. The authors conclude that these findings do not support PES-guided PEEP titration in ARDS. A thoughtful editorial accompanies the manuscript in the same issue of JAMA.