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1. Error in Table 2?

   • Duncan Chambers, Research Fellow

   CRD, University of York, UK

   I believe there is an error in Table 2 that could cause confusion. Under the outcomes 'Use of rescue therapy' and 'Mortality in patients with rescue therapy', the data in the 'Low PEEP' column refer to the 'High PEEP' group and vice versa.

   Conflict of Interest:

   None declared

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   Published October 30, 2009
2. HIGH VS. LOW PEEP IN ARDS

   • Federico Gordo-Vidal, MD
   • Eduardo Palencia-Herrejón, Ana Abella-Alvarez and Victoria Enciso-Calderón

   Hospital del Henares

   We read with great interest the meta-analysis published by Putensen et al (1). We agree with its conclusions, however we would like to add some suggestions.

   Our group conducted previously a meta-analysis (2) on the effect of higher vs. lower PEEP levels in patients with ARDS. Four articles evaluated the effect of PEEP levels on mortality, not showing significant differences (RR 0.73, 95% CI 0.49 to 1.10). However, an analysis of the three studies in which PEEP level was individualized according to pulmonary mechanics (pressure-volume curve) found a significant decrease in mortality (RR 0.59, 95% CI: 0.43 to 0.82).

   When the definitive results of two new studies were known, we updated our meta-analysis (3). Pooling the results of the four previous studies and the two recent ones, the use of higher PEEP levels, regardless of PEEP selection mode, did’n reached a statistically significant mortality reduction in a random effects model (RR 0.85, 95% CI 0.71 to 1.01) (p = 0.06).

   The favorable effect of the use of the high PEEP (individualized based on the findings of pulmonary mechanics), can be overestimated, it should be noted that in the 3 studies analyzed in the meta-analysis of Putensen et al (1), control groups (low PEEP groups) used PEEP levels well above those used in clinical practice (4).

   We conclude that higher PEEP levels are probably beneficial in ARDS, especially in the most severe ones, however PEEP should not be set to fixed levels, but tailored to individual pulmonary mechanics.

   REFERENCES

   1. Putensen C, Theuerkauf N, Zinserling J, Wrigge H, Pelosi P. Meta- analysis: Ventilation Strategies and Outcomes of the Acute Respiratory Distress Syndrome and Acute Lung Injury. Ann Intern Med. 2009;151(8):566- 76.

   2. Gordo-Vidal F, Gomez-Tello V, Palencia-Herrejon E, Latour-Perez J, Sanchez-Artola B, Diaz-Alersi R. High PEEP vs. conventional PEEP in the acute respiratory distress syndrome: a systematic review and meta- analysis. Med Intensiva. 2007;31(9):491-501.

   3. Gordo-Vidal F, Gomez-Tello V, Palencia-Herrejon E, Latour-Perez J. Impact of two new studies on the results of a meta-analysis on the application of high PEEP in patients with acute respiratory distress syndrome. Med Intensiva. 2008;32(6):316-7.

   4. Esteban A, Ferguson ND, Meade MO, Frutos-Vivar F, Apezteguia C, Brochard L, et al. Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med. 2008;177(2):170-7.

   Conflict of Interest:

   None declared

   Submit response
   Published October 26, 2009