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. 2024 Oct 4;3(6):e0060.
doi: 10.1097/EA9.0000000000000060. eCollection 2024 Dec.

Determination of positive end-expiratory pressure in COVID-19-related acute respiratory distress syndrome: A systematic review

Alexandra Sachkova  1 , Marike Andreas  1 , Daniel Heise  1 , Martin Golinski  1 , Caspar Stephani  1 , Steffen Dickel  1 , Clemens Grimm  1 , Ina Monsef  1 , Vanessa Piechotta  1 , Nicole Skoetz  1 , Sven Laudi  1 , Onnen Moerer  1
Affiliations

Determination of positive end-expiratory pressure in COVID-19-related acute respiratory distress syndrome: A systematic review

Alexandra Sachkova et al. Eur J Anaesthesiol Intensive Care. .

Abstract

Background: The impact of high positive end-expiratory pressure (PEEP) ventilation and the optimization of PEEP titration in COVID-19-induced acute respiratory distress syndrome (ARDS) continues to be a subject of debate. In this systematic review, we investigated the effects of varying PEEP settings on patients with severe ARDS primarily resulting from COVID-19 (C-ARDS).

Objectives: Does higher or lower PEEP improve the outcomes in COVID-19 ARDS? Does individually titrated PEEP lead to better outcomes compared with PEEP set by standardised (low and high ARDS network PEEP tables) approaches? Does the individually set PEEP (best PEEP) differ from PEEP set according to the standardised approaches (low and high ARDS network PEEP tables)?

Design: Systematic review of observational studies without metaanalysis.

Data sources: We performed an extensive systematic literature search in Cochrane COVID-19 Study Register (CCSR), PubMed, Embase.com, Web of Science Core Collection, World Health Organization COVID-19 Global literature on coronavirus disease, World Health Organization International Clinical Trials Registry Platform (ICTRP), medRxiv, Cochrane Central Register of Controlled Trials until 24/01/2024.

Eligibility criteria: Ventilated adult patients (≧18 years) with C-ARDS.

Results: We screened 16 026 records, evaluated 119 full texts, and included 12 studies (n = 1431 patients) in our final data synthesis, none of them being a randomised controlled trial. The heterogeneity of study procedures and populations did not allow conduction of a meta-analysis. The results of those studies that compared lower and higher PEEP strategies in C-ARDS were ambiguous pointing out either positive effects on oxygenation with high levels of PEEP, or negative changes in lung mechanics.

Conclusion: The available evidence does not provide sufficient guidance for recommendations on optimal PEEP settings in C-ARDS. In general, well designed platform studies are needed to answer the questions raised in this review and, in particular, to investigate the use of individualised PEEP titration techniques and the inclusion of patients with different ARDS entities, severities and disease stages.

Title registration: Our systematic review protocol was registered with the international prospective register of systematic reviews (PROSPERO 2021: CRD42021260303).

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Conflict of interest statement

Conflicts of interest: all authors are members of the national CEOsys network Germany (see funding). AS, MA, DH, MG, CS, SD, CG, IM, VP, NS and SL: no competing interests, OM and AS: member of the Coordinating Guideline Committee (German S3 Guideline Invasive Ventilation and Extracorporeal Membrane Oxygenation in Acute Respiratory Insufficiency), Coordinating Committee (German guideline on prolonged weaning from mechanical ventilation). He received honoraria for workshops on hemodynamic monitoring supported by Getinge and for lectures on coagulation from CSL Behring.

Figures

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Graphical abstract
Fig. 1
Fig. 1
Schematic representation of literature selection process.
Fig. 2
Fig. 2
Gas exchange and lung mechanics under high and low positive end-expiratory pressure.
Fig. 3
Fig. 3
Optimal positive end-expiratory pressure level determined in reviewed studies.
See this image and copyright information in PMC

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References

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