What does this research mean for the field?

Esophageal pressure-guided PEEP titration in ARDS patients does not significantly reduce 28-day mortality, but demonstrates potential benefits in clinical outcomes such as reduced ICU length of stay and increased ventilator-free days. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

The aim is to assess the effects of esophageal pressure guided PEEP titration on outcomes in ARDS patients.

May 20, 2026

C55-15 Systematic Review and Meta-Analysis of Fixed Versus Customized Peep Settings in Acute Respiratory Distress Syndrome

Key Points

The aim is to assess the effects of esophageal pressure guided PEEP titration on outcomes in ARDS patients.
Conducted a systematic review and meta-analysis including three randomized controlled trials.
Evaluated mortality and ICU length of stay in ventilated adults with moderate to severe ARDS.
Applied a random-effects model due to moderate heterogeneity in data.
Observed a 39% reduction in 28-day mortality risk in the esophageal balloon guided group (OR 0.61; 95% CI: 0.29-1.28), but not statistically significant (p=0.19).
Beitler 2019 showed no significant benefit in mortality (32.4% vs 30.6%; p=0.880).
The Sun 2024 study indicated a significant reduction in ICU length of stay (24.73 ± 4.85 days vs 29.26 ± 5.92 days; p<0.001) and more ventilation-free days (15.36 ± 3.39 days vs 11.23 ± 3.17 days; p<0.001).

Abstract

Abstract Protective ventilation is a fundamental pillar in the management of acute respiratory failure (ARF), aiming to minimize ventilator-induced lung injury. However, optimal Positive End-Expiratory Pressure (PEEP) titration remains a challenge, especially in patients with Acute Respiratory Distress Syndrome (ARDS) Measuring transpulmonary pressure using an esophageal balloon offers and individualized approach by estimating pleural pressure, allowing the real alveolar pressure to be differentiated from the externally applied pressure. This advanced monitoring seeks to optimize alveolar recruitment and reduce overdistension. We conducted a systematic review and meta-analysis to evaluate whether PEEP titration guided by esophageal pressure impacts mortality and intensive care unit length of stay in ventilated adults. Three randomized controlled trials in patients with moderate to severe ARDS were included: Talmor 2008, Beitler 2019 and Sun 2024The meta-analysis, performed under a random-effects model due to moderate heterogeneity (I2=57.21%), revealed a 39% reduction in the relative risk of 28 day mortality in the esophageal ballon guided group (overall OR 0.61; 95% CI: 0.29-1.28), although this difference did not reach statistical significance (p = 0.19)Individually, studies with a lower risk of bias, such as the Beitler 2019, showed no significant benefit in 28 day mortality (32.4% vs 30.6%; p = 0.880). In contrast, the Sun 2024 study suggested a significant reduction in ICU length of stay (24.73 +/- 4.85 days vs 29.26 +/- 5.92 days; p 0.001) and higher number of ventilation free days (15.36 +/- 3.39 days vs 11.23 +/- 3.17 days; p 0.001)While the combined effect on mortality was not statistically significant, the observed trend and the benefits in surrogate and clinical outcomes (ventilator free days, ICU stay) suggest that esophageal pressure guided PEEP titration is a strategy with high physiological impact and the potential to improve outcomes, particularly in specific ARDS subpopulations. This abstract is funded by: None

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Cite This Study

Perez et al. (Fri,) studied this question.

synapsesocial.com/papers/6a0d5000f03e14405aa9b97b https://doi.org/https://doi.org/10.1093/ajrccm/aamag162.3319

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