Higher PEEP in patients with acute lung injury: a systematic review and meta-analysis

Respir Care. 2011 May;56(5):568-75. doi: 10.4187/respcare.01011. Epub 2011 Jan 27.


Background: Studies of ventilation strategies that included higher PEEP in patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) have yielded conflicting results.

Objective: To determine whether higher PEEP during volume-limited and pressure-limited ventilation is associated with 28-day mortality or barotrauma rates in patients with ALI/ARDS.

Methods: We searched MEDLINE, CENTRAL, EMBASE, CINAHL, Web of Science, and the bibliographies of retrieved papers to identify randomized controlled trials that compared higher and lower PEEP in adult patients with ALI/ARDS who were already receiving volume-limited or pressure-limited ventilation. Two of us independently abstracted study-level data, including study design, patient characteristics, study methods, intervention, and main results. We pooled the study-level data with a random-effects model, unless heterogeneity was low (I(2) < 50%), in which case we used a fixed-effects model. The primary outcome was 28-day mortality.

Results: Four randomized trials (2,360 participants) were evaluated. Higher PEEP had a nonsignificant trend toward lower 28-day mortality (pooled relative risk 0.90, 95% CI 0.79-1.02). There was no difference in barotrauma between the 2 groups (pooled relative risk 1.17, 95% CI 0.90-1.52). Two studies reported an adjusted hospital death rate, and the pooled results of sensitivity analysis with those adjusted rates were identical to those of the unadjusted analysis.

Conclusions: In 4 recent studies that used volume-limited or pressure-limited ventilation in ALI/ARDS patients, higher PEEP was not associated with significantly different short-term mortality or barotrauma. This study does not support the routine use of higher PEEP in patients with ALI/ARDS.

Publication types

  • Meta-Analysis
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Acute Lung Injury / mortality
  • Acute Lung Injury / therapy*
  • Humans
  • Positive-Pressure Respiration / methods*
  • Practice Guidelines as Topic
  • Survival Rate / trends
  • United States / epidemiology