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Purpose  In patients with acute respiratory distress syndrome (ARDS), lung recruitment could be maximised with the use of recruitment manoeuvres (RM) or applying a positive end-expiratory pressure (PEEP) higher than what is necessary to maintain minimal adequate oxygenation. We aimed to determine whether ventilation strategies using  higher  PEEP and/or RMs could decrease mortality in patients with ARDS.    Methods  We searched MEDLINE, EMBASE and CENTRAL from 1996 to December 2019, included randomized controlled trials comparing ventilation with  higher PEEP  and/or RMs to strategies with lower PEEP and no RMs in patients with ARDS. We computed pooled estimates with a DerSimonian-Laird mixed-effects model, assessing mortality and incidence of barotrauma, population characteristics, physiologic variables and ventilator settings. We performed a trial sequential analysis (TSA) and a meta-regression.    Results  Excluding two studies that used tidal volume ( V  T ) reduction as co-intervention, we included 3870 patients from 10 trials using higher PEEP alone ( n  = 3), combined with RMs ( n  = 6) or RMs alone ( n  = 1). We did not observe differences in mortality (relative risk, RR 0.96, 95% confidence interval, CI [0.84–1.09],  p  = 0.50) nor in incidence of barotrauma (RR 1.22, 95% CI [0.93–1.61],  p  = 0.16). In the meta-regression, the PEEP difference between intervention and control group at day 1 and the use of RMs were not associated with increased risk of barotrauma. The TSA reached the required information size for mortality ( n  = 2928), and the z-line surpassed the futility boundary.    Conclusions  At low  V  T , the routine use of higher PEEP and/or RMs did not reduce mortality in unselected patients with ARDS.    Trial registration  PROSPERO  CRD42017082035 .

intensive care medicine experimental

Effects of higher PEEP and recruitment manoeuvres on mortality in patients with ARDS: a systematic review, meta-analysis, meta-regression and trial sequential analysis of randomized controlled trials