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Association of Driving Pressure With Mortality Among Ventilated Patients With Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis*

Aoyama, Hiroko, MD, MScCH1; Pettenuzzo, Tommaso, MD1; Aoyama, Kazuyoshi, MD, PhD(c), EDIC2; Pinto, Ruxandra, PhD3; Englesakis, Marina, MLIS4; Fan, Eddy, MD, PhD, FRCPC1

doi: 10.1097/CCM.0000000000002838
Review Articles

Objectives: A recent post hoc analysis suggested that driving pressure may be more important than traditional ventilatory variables in determining outcome in mechanically ventilated patients with acute respiratory distress syndrome. We conducted a systematic review and meta-analysis to summarize the risk of mortality for higher versus lower driving pressure.

Data Sources: MEDLINE, EMBASE, PubMed, CINAHL, and Cochrane CENTRAL from inception to February 10, 2017.

Study Selection: Studies including mechanically ventilated adult patients with acute respiratory distress syndrome, reporting driving pressure and mortality.

Data Extraction: Seven studies including five secondary analysis of previous randomized controlled trials and two observational studies (6,062 patients) were eligible for study. All studies were judged as having a low risk of bias. Median (interquartile range) driving pressure between higher and lower driving pressure groups was 15 cm H2O (14–16 cm H2O). Median (interquartile range) mortality of all included studies was 34% (32–38%).

Data Synthesis: In the meta-analyses of four studies (3,252 patients), higher driving pressure was associated with a significantly higher mortality (pooled risk ratio, 1.44; 95% [CI], 1.11–1.88; I 2 = 85%). A sensitivity analysis restricted to the three studies with similar driving pressure cutoffs (13–15 cm H2O) demonstrated similar results (pooled risk ratio, 1.28; 95% CI, 1.14–1.43; I 2 = 0%).

Conclusions: Our study confirmed an association between higher driving pressure and higher mortality in mechanically ventilated patients with acute respiratory distress syndrome. These findings suggest a possible range of driving pressure to be evaluated in clinical trials. Future research is needed to ascertain the benefit of ventilatory strategies targeting driving pressure in patients with acute respiratory distress syndrome.

1Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.

2Department of Anesthesia, University of Toronto, Toronto, ON, Canada.

3Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.

4Health Sciences Library, Toronto General Hospital, Toronto, ON, Canada.

*See also p. 338.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Drs. Aoyama and Fan conceived this article. Drs. Aoyama, Pettenuzzo, Englesakis, and Fan performed the systematic review. Drs. Aoyama, Aoyama, and Pinto performed the analysis on the result of the literature search, and Drs. Pettenuzzo, Aoyama, Pinto, and Fan provided input on the interpretation. Drs. Aoyama and Aoyama wrote the initial draft of the article, and Drs. Pettenuzzo, Pinto, Englesakis, and Fan helped draft the final version, which was approved by all authors.

The authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: eddy.fan@uhn.ca

Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.