Determination of positive end-expiratory pressure in COVID-19-related acute respiratory distress syndrome: A systematic review.
Summary
This PROSPERO-registered systematic review (CRD42021260303) screened 16,026 records, evaluated 119 full texts, and included 12 observational studies on PEEP strategies in COVID-19 ARDS. Evidence did not support definitive recommendations for higher vs lower PEEP or standardized vs individualized PEEP titration. The authors call for well-designed platform trials to test individualized, physiology-guided PEEP across ARDS phenotypes and stages.
Key Findings
- Screened 16,026 records, assessed 119 full texts, and included 12 observational studies on PEEP in COVID-19 ARDS.
- No conclusive advantage of higher vs lower PEEP or standardized vs individualized PEEP titration was identified.
- Calls for platform trials to test individualized, physiology-guided PEEP across ARDS phenotypes, severities, and stages.
Clinical Implications
Avoid rigid adherence to high- or low-PEEP tables in COVID-19 ARDS; integrate bedside physiology and recruitability assessment while awaiting trials. Prioritize enrollment in platform studies testing individualized titration.
Why It Matters
Clarifies the limits of existing evidence and redirects the field toward individualized, physiology-based PEEP research rather than one-size-fits-all protocols.
Limitations
- Only observational studies were available; heterogeneity precluded meta-analysis
- Findings limited to COVID-19 ARDS and may not generalize to non-COVID ARDS phenotypes
Future Directions
Conduct platform RCTs incorporating recruitability and lung mechanics to individualize PEEP; include diverse ARDS etiologies and disease stages.
Study Information
- Study Type
- Systematic Review
- Research Domain
- Treatment
- Evidence Level
- II - Systematic review of observational studies without meta-analysis; moderate-quality evidence.
- Study Design
- OTHER