PEEP Titration to Minimize Driving Pressure in Subjects With ARDS: A Prospective Physiological Study

BACKGROUND: Observational studies report that lower driving pressure (ie, the difference between plateau pressure and PEEP) is associated with improved survival in patients with ARDS and may be a key mediator of lung-protective ventilation strategies. The primary objective of this study was to characterize reductions in driving pressure that could be achieved through changes in PEEP. METHODS: In this prospective physiological pilot study, 10 subjects with ARDS were placed on PEEP according to the ARDS Network Lower PEEP/F-IO2 Table. PEEP was adjusted in small increments and decrements above and below this initial PEEP, and driving pressure was measured at each PEEP level. Subsequently, PEEP was set at the level resulting in the lowest driving pressure, and driving pressure was measured after 1, 5, 15, and 30 min to assess stability over time at constant PEEP. RESULTS: All subjects had ARDS with a median (interquartile range [IQR]) P-aO2/F-IO2 of 116 (98-132) at enrollment. Median (IQR) driving pressure at baseline was 14 (13-17) cm H2O. After PEEP titration, median driving pressure decreased to 13 (12-14) cm H2O. The largest reduction in driving pressure was 4 cm H2O. Two subjects had no change in driving pressure at multiple PEEP levels. To achieve the lowest driving pressure, final PEEP was increased in 6 subjects and decreased in 4 subjects from the baseline PEEP prescribed by the ARDS Network Lower PEEP/F-IO2 Table. Driving pressure reached equilibrium within 1-5 min and remained stable for 30 min following PEEP titration. CONCLUSIONS: PEEP titration had a variable effect in changing driving pressure across this small sample of ARDS subjects. In some subjects, PEEP was decreased from values given in the ARDS Network Lower PEEP/F-IO2 Table to minimize driving pressure. Changes in driving pressure stabilized within a few minutes of PEEP titration.