Background: Lower driving pressure is associated with better outcomes in patients with acute respiratory distress syndrome (ARDS) based on observational studies. However, individual randomized controlled trials provided inconclusive evidence. We synthesized evidence from randomized controlled trials to examine whether implementation of driving pressure-limiting strategies is feasible and improves outcomes.
Methods: This meta-analysis was registered with PROSPERO (CRD420251141653). PubMed, Scopus, CENTRAL and references were searched for trials comparing driving pressure-limiting strategies on top of lung protective ventilation ("intervention" group) versus lung protective ventilation alone ("control" group) in ARDS. Outcomes were feasibility of intervention, all-cause mortality, ventilator-free days and length of intensive care unit (ICU) stay.
Results: Four trials, enrolling 431 patients and implementing heterogenous driving pressure-limiting strategies (namely, tidal volume reduction and/or positive end-expiratory pressure titration), were included. There were no statistically significant mean differences in post-randomization driving pressure (namely, - 2.17, - 2.09 and - 2.15 cmH2O on study day 1, 2 and 3, respectively) between groups. There was no statistically significant difference between "intervention" versus "control" group in terms of mortality [35.7% versus 39.0%; relative risk 0.63, 95% confidence interval (CI) 0.20 to 1.94, p = 0.28] or ventilator-free days (p = 0.88). Driving pressure-limiting strategies were associated with shorter length of ICU stay (mean difference - 2.40 days, 95% CI - 3.31 to - 1.49, p = 0.004).
Conclusions: When lung protective ventilation is already applied, further limitation of driving pressure may be hard to achieve. This inability to meaningfully limit driving pressure might explain the neutral effect of driving pressure-limiting strategies on outcomes, such as mortality and ventilator-free days.
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