Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
Respir Care. 2011 May;56(5):568-75. doi: 10.4187/respcare.01011. Epub 2011 Jan 27.
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.
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.
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.
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.
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.
包括急性肺损伤（ALI）或急性呼吸窘迫综合征（ARDS）患者更高 PEEP 的通气策略研究结果相互矛盾。
确定在容量限制和压力限制通气中使用更高的 PEEP 是否与 ALI/ARDS 患者的 28 天死亡率或气压伤发生率相关。
我们检索了 MEDLINE、CENTRAL、EMBASE、CINAHL、Web of Science 和检索文献的参考文献，以确定比较已接受容量限制或压力限制通气的 ALI/ARDS 成年患者中较高和较低 PEEP 的随机对照试验。我们两人独立提取研究水平数据，包括研究设计、患者特征、研究方法、干预措施和主要结果。我们使用随机效应模型汇总研究水平数据，除非异质性低（I²<50%），在这种情况下我们使用固定效应模型。主要结局是 28 天死亡率。
评估了 4 项随机试验（2360 名参与者）。较高的 PEEP 有降低 28 天死亡率的趋势（汇总相对风险 0.90，95%CI 0.79-1.02）。两组之间气压伤无差异（汇总相对风险 1.17，95%CI 0.90-1.52）。两项研究报告了调整后的住院死亡率，并且对这些调整后率进行敏感性分析的汇总结果与未调整分析的结果相同。
在最近的 4 项使用 ALI/ARDS 患者容量限制或压力限制通气的研究中，较高的 PEEP 与短期死亡率或气压伤无显著差异无关。本研究不支持在 ALI/ARDS 患者中常规使用较高的 PEEP。
