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Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome.
N Engl J Med. 2004 Jul 22; 351(4):327-36.NEJM

Abstract

BACKGROUND

Most patients requiring mechanical ventilation for acute lung injury and the acute respiratory distress syndrome (ARDS) receive positive end-expiratory pressure (PEEP) of 5 to 12 cm of water. Higher PEEP levels may improve oxygenation and reduce ventilator-induced lung injury but may also cause circulatory depression and lung injury from overdistention. We conducted this trial to compare the effects of higher and lower PEEP levels on clinical outcomes in these patients.

METHODS

We randomly assigned 549 patients with acute lung injury and ARDS to receive mechanical ventilation with either lower or higher PEEP levels, which were set according to different tables of predetermined combinations of PEEP and fraction of inspired oxygen.

RESULTS

Mean (+/-SD) PEEP values on days 1 through 4 were 8.3+/-3.2 cm of water in the lower-PEEP group and 13.2+/-3.5 cm of water in the higher-PEEP group (P<0.001). The rates of death before hospital discharge were 24.9 percent and 27.5 percent, respectively (P=0.48; 95 percent confidence interval for the difference between groups, -10.0 to 4.7 percent). From day 1 to day 28, breathing was unassisted for a mean of 14.5+/-10.4 days in the lower-PEEP group and 13.8+/-10.6 days in the higher-PEEP group (P=0.50).

CONCLUSIONS

These results suggest that in patients with acute lung injury and ARDS who receive mechanical ventilation with a tidal-volume goal of 6 ml per kilogram of predicted body weight and an end-inspiratory plateau-pressure limit of 30 cm of water, clinical outcomes are similar whether lower or higher PEEP levels are used.

Authors+Show Affiliations

Johns Hopkins University, Baltimore, USA.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Clinical Trial
Comparative Study
Journal Article
Multicenter Study
Randomized Controlled Trial
Research Support, U.S. Gov't, P.H.S.

Language

eng

PubMed ID

15269312

Citation

Brower, Roy G., et al. "Higher Versus Lower Positive End-expiratory Pressures in Patients With the Acute Respiratory Distress Syndrome." The New England Journal of Medicine, vol. 351, no. 4, 2004, pp. 327-36.
Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med. 2004;351(4):327-36.
Brower, R. G., Lanken, P. N., MacIntyre, N., Matthay, M. A., Morris, A., Ancukiewicz, M., Schoenfeld, D., & Thompson, B. T. (2004). Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. The New England Journal of Medicine, 351(4), 327-36.
Brower RG, et al. Higher Versus Lower Positive End-expiratory Pressures in Patients With the Acute Respiratory Distress Syndrome. N Engl J Med. 2004 Jul 22;351(4):327-36. PubMed PMID: 15269312.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. AU - Brower,Roy G, AU - Lanken,Paul N, AU - MacIntyre,Neil, AU - Matthay,Michael A, AU - Morris,Alan, AU - Ancukiewicz,Marek, AU - Schoenfeld,David, AU - Thompson,B Taylor, AU - ,, PY - 2004/7/23/pubmed PY - 2004/8/3/medline PY - 2004/7/23/entrez SP - 327 EP - 36 JF - The New England journal of medicine JO - N. Engl. J. Med. VL - 351 IS - 4 N2 - BACKGROUND: Most patients requiring mechanical ventilation for acute lung injury and the acute respiratory distress syndrome (ARDS) receive positive end-expiratory pressure (PEEP) of 5 to 12 cm of water. Higher PEEP levels may improve oxygenation and reduce ventilator-induced lung injury but may also cause circulatory depression and lung injury from overdistention. We conducted this trial to compare the effects of higher and lower PEEP levels on clinical outcomes in these patients. METHODS: We randomly assigned 549 patients with acute lung injury and ARDS to receive mechanical ventilation with either lower or higher PEEP levels, which were set according to different tables of predetermined combinations of PEEP and fraction of inspired oxygen. RESULTS: Mean (+/-SD) PEEP values on days 1 through 4 were 8.3+/-3.2 cm of water in the lower-PEEP group and 13.2+/-3.5 cm of water in the higher-PEEP group (P<0.001). The rates of death before hospital discharge were 24.9 percent and 27.5 percent, respectively (P=0.48; 95 percent confidence interval for the difference between groups, -10.0 to 4.7 percent). From day 1 to day 28, breathing was unassisted for a mean of 14.5+/-10.4 days in the lower-PEEP group and 13.8+/-10.6 days in the higher-PEEP group (P=0.50). CONCLUSIONS: These results suggest that in patients with acute lung injury and ARDS who receive mechanical ventilation with a tidal-volume goal of 6 ml per kilogram of predicted body weight and an end-inspiratory plateau-pressure limit of 30 cm of water, clinical outcomes are similar whether lower or higher PEEP levels are used. SN - 1533-4406 UR - https://www.unboundmedicine.com/medline/citation/15269312/Higher_versus_lower_positive_end_expiratory_pressures_in_patients_with_the_acute_respiratory_distress_syndrome_ L2 - http://www.nejm.org/doi/full/10.1056/NEJMoa032193?url_ver=Z39.88-2003&amp;rfr_id=ori:rid:crossref.org&amp;rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -