The future of driving pressure: a primary goal for mechanical ventilation?

• Published in: Journal of intensive care Vol. 6; no. 1; p. 64
• Main Authors: Aoyama, Hiroko, Yamada, Yoshitsugu, Fan, Eddy
• Format: Journal Article
• Language: English
• Published: England BioMed Central Ltd 04.10.2018; BioMed Central; BMC
• Subjects: Acute respiratory distress syndrome; Adult respiratory distress syndrome; Analysis; Care and treatment; Clinical practice guideline; Clinical practice guidelines; Clinical trials; Continuous positive airway pressure; Driving pressure; Intensive care units; Lung protective mechanical ventilation; Mechanical ventilation; Mortality; Physiological aspects; Respiratory therapy; Ventilators; Acute respiratory distress syndrome; Intensive care units; Driving pressure; Clinical practice guideline; Lung protective mechanical ventilation; Mortality
• DOI: 10.1186/s40560-018-0334-4
• ISSN: 2052-0492

Management of patients with acute respiratory distress syndrome (ARDS) remains supportive with lung protective mechanical ventilation. In this article, we discuss the physiological concept of driving pressure, current data, ongoing trials, and future directions needed to clarify the role of driving pressure in patients with ARDS. Driving pressure is the plateau airway pressure minus PEEP. It can also be expressed as the ratio of tidal volume to respiratory system compliance, indicating the decreased functional size of the lung observed in patients with ARDS (i.e., baby lung). Driving pressure as a strong predictor of mortality in patients with ARDS is supported by a post hoc analysis of previous randomized controlled trials and a subsequent meta-analysis. Importantly, the meta-analysis suggested targeting driving pressure below 13-15 cmH2O. Ongoing clinical trials of driving pressure in patients with ARDS focus mainly on physiological rather than clinical outcome but will provide important insights for the design of future clinical trials. Currently, no definite clinical recommendations on the routine use of driving pressure in patients with ARDS can be made, as the available data are hypothesis-generating. Randomized controlled trials are needed to evaluate the efficacy of a driving pressure-based ventilation strategy.