title: Higher PEEP in patients with acute lung injury: a systematic review and meta-analysis.
abstract: 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.
authors.affiliation: Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA. ecd28@case.edu
authors.forename: Elliott C
authors.initials: EC
authors.lastname: Dasenbrook
authors.forename: Dale M
authors.initials: DM
authors.lastname: Needham
authors.forename: Roy G
authors.initials: RG
authors.lastname: Brower
authors.forename: Eddy
authors.initials: E
authors.lastname: Fan
mesh_terms: D055371:Acute Lung Injury / Q000401:mortality / Q000628:therapy*; D006801:Humans; D011175:Positive-Pressure Respiration / Q000379:methods*; D017410:Practice Guidelines as Topic; D015996:Survival Rate / Q000639:trends; D014481:United States / Q000453:epidemiology