Association of PEEP and Lung Recruitment Selection Strategies with Mortality in Acute Respiratory Distress Syndrome: A Systematic Review and Network Meta-Analysis.

RationaleThe most beneficial positive end-expiratory pressure (PEEP) selection strategy in patients with acute respiratory distress syndrome (ARDS) is unknown and current practice is variable.ObjectivesTo compare the relative effects of different PEEP selection strategies on mortality in adults with moderate to severe ARDS.MethodsWe conducted a network meta-analysis using a Bayesian framework. Certainty of evidence was evaluated using GRADE methodology.ResultsWe included 18 randomized trials (4646 participants). In comparison to a lower PEEP strategy, the posterior probability of mortality benefit from a higher PEEP without lung recruitment maneuver (LRM) strategy was 99% (RR 0.77, 95% Crl 0.60-0.96, high certainty), the posterior probability of benefit of the Pes-guided strategy was 87% (RR 0.77, 95% CrI 0.48-1.22, moderate certainty), the posterior probability of benefit of a higher PEEP with brief LRM strategy was 96% (RR 0.83, 95% CrI 0.67-1.02, moderate certainty), and the posterior probability of increased mortality from a higher PEEP with prolonged LRM strategy was 77% (RR 1.06, 95% Crl 0.89-1.22, low certainty). In comparison to a higher PEEP without LRM strategy, the posterior probability of increased mortality from a higher PEEP with prolonged LRM strategy was 99% (RR 1.37, 95% CrI 1.04-1.81, moderate certainty).Conclusions and relevanceIn patients with moderate to severe ARDS, higher PEEP without LRM is associated with a lower risk of death as compared to lower PEEP. A higher PEEP with prolonged LRM strategy is associated with increased risk of death when compared to higher PEEP without LRM.