Driving pressure in acute respiratory distress syndrome for developing a protective lung strategy: A systematic review

Table 1 Berlin criteria for acute respiratory distress syndrome

Features	Mild	Moderate	Severe
Timing	Acute onset within one week of a known respiratory clinical insult or new/worsening respiratory symptoms
Hypoxemia	200 < PaO2/FiO2 ≤ 300 with PEEP or CPAP ≥ 5 cmH2O	100 < PaO2/FiO2 ≤ 200 with PEEP ≥ 5 cmH2O	PaO2/FiO2 < 100 with PEEP ≥ 5 cmH2O
Origin of edema	Respiratory failure is associated with known risk factors and is not fully explained by cardiac failure or fluid overload. An objective assessment of cardiac failure or fluid overload is needed if no risk factor is present
Radiologic abnormalities	Bilateral opacities		Opacities involving at least three quadrants
Additional physiological derangement	N/A		Crs < 40 mL/cmH2O1

¹Respiratory system compliance.

PaO₂: Partial pressure of arterial oxygen; FiO₂: Fractional inspired of oxygen; PEEP: Positive end of expiratory pressure; Crs: Compliance; CPAP: Continuous positive airway pressure; N/A: Not applicable.

Table 2 Summary of included studies

Ref.	Title of the article	Objective of the article	Methodology of the article	Number of patients included in the article	Summary of the results	How driving pressure is described in the article	Mortality rate or mortality outcome mentioned in article	Effect of driving pressure on mortality
Gattinoni et al[22], 2006	Lung recruitment in patients with the acute respiratory distress syndrome	Studying lung recruitment in ARDS	Prospective study	Not specified	Lung recruitment beneficial for ARDS	Not described	Yes	Lung recruitment beneficial for ARDS
Meade et al[16], 2008	Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: A randomized controlled trial	To study the effect of ventilation strategy on ARDS	Randomized controlled trial	Not specified	Low tidal volumes and high PEEP beneficial for ARDS	Not described	Yes	Low tidal volumes and high PEEP beneficial for ARDS
Mercat et al[21], 2008	Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: A randomized controlled trial	To study the effect of PEEP setting on ARDS	Randomized controlled trial	Not specified	High PEEP beneficial for ARDS	Not described	Yes	High PEEP beneficial for ARDS
Retamal et al[25], 2015	High PEEP levels are associated with overdistension and tidal recruitment/derecruitment in ARDS patients	To study the effects of high PEEP levels on lung mechanics in ARDS patients	Prospective study	Not specified	High PEEP levels associated with overdistension and tidal recruitment/derecruitment	Not described	Yes	High PEEP levels associated with overdistension and tidal recruitment/derecruitment
Borges et al[28], 2015	Altering the mechanical scenario to decrease the driving pressure	To study the effect of altering mechanical scenarios on DP	Prospective study	Not specified	Altering mechanical scenarios can decrease DP	Described as the difference between plateau pressure and PEEP	Yes	Altering mechanical scenarios can decrease DP
Bellani et al[8], 2016	Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries	To study the epidemiology and outcomes of ARDS	Prospective study	459 ICUs	High mortality rate and geographical variation in ARDS	Not described	Yes	Not specified
Chiumello et al[19], 2016	Airway driving pressure and lung stress in ARDS patients	To study the relationship between driving pressure and lung stress in ARDS	Retrospective study	150 patients	DP correlated with lung stress	Described as the difference between plateau pressure and PEEP	Yes	Driving pressure correlated with lung stress
Baedorf Kassis et al[31], 2016	Mortality and pulmonary mechanics in relation to respiratory system and transpulmonary driving pressures in ARDS	To study the relationship between pulmonary mechanics and mortality in ARDS	Retrospective study	150 patients	DP correlated with lung stress and mortality	Described as the difference between plateau pressure and PEEP	Yes	DP correlated with lung stress and mortality
Guérin et al[33], 2016	Effect of driving pressure on mortality in ARDS patients during lung protective mechanical ventilation in two randomized controlled trials	To study the effect of DP on mortality in ARDS	Randomized controlled trial	Not specified	DP correlated with mortality in ARDS	Described as the difference between plateau pressure and PEEP	Yes	DP correlated with mortality in ARDS
Xie et al[29], 2017	The effects of low tidal ventilation on lung strain correlate with respiratory system compliance	To study the effects of low tidal ventilation on lung strain	Prospective study	Not specified	Low tidal ventilation correlated with respiratory system compliance	Described as the difference between plateau pressure and PEEP	Yes	Low tidal ventilation correlated with respiratory system compliance
Mezidi et al[36], 2017	Effect of end-inspiratory plateau pressure duration on driving pressure	To study the effect of plateau pressure duration on DP	Prospective study	Not specified	Plateau pressure duration affects DP	Described as the difference between plateau pressure and PEEP	Yes	Plateau pressure duration affects DP
Das et al[10], 2019	What links ventilator driving pressure with survival in acute respiratory distress syndrome?	To study the link between ventilator driving pressure and survival in ARDS	Computational study	Not specified	Link between DP and survival	Described as the difference between plateau pressure and PEEP	Yes	Driving pressure linked to survival
Collino et al[26], 2019	Positive end-expiratory pressure and mechanical power	To study the effect of PEEP and mechanical power on ARDS	Prospective study	Not specified	High PEEP levels associated with overdistension and tidal recruitment/derecruitment	Not described	Yes	High PEEP levels associated with overdistension and tidal recruitment/derecruitment
Dai et al[32], 2019	Risk factors for outcomes of acute respiratory distress syndrome patients: a retrospective study	To identify risk factors for ARDS outcomes	Retrospective study	Not specified	Identified risk factors for ARDS outcomes	Not described	Yes	Identified risk factors for ARDS outcomes
Bellani et al[37], 2019	Driving pressure is associated with outcome during assisted ventilation in acute respiratory distress syndrome	To study the association of DP with outcomes during assisted ventilation in ARDS	Prospective study	Not specified	DP associated with outcomes during assisted ventilation in ARDS	Described as the difference between plateau pressure and PEEP	Yes	DP associated with outcomes during assisted ventilation in ARDS
Yehya et al[30], 2021	Response to ventilator adjustments for predicting ARDS mortality: Driving pressure versus oxygenation	To compare the predictive value of DP and oxygenation on ARDS mortality	Comparative study	Not specified	DP more informative about ventilator adjustments than oxygenation	Described as the difference between plateau pressure and PEEP	Yes	DP more informative about ventilator adjustments than oxygenation
Dianti et al[17], 2021	Comparing the effects of tidal volume, driving pressure, and mechanical power on mortality in trials of lung-protective mechanical ventilation	Comparing the effects of tidal volume, driving pressure, and mechanical power on mortality	Comparative study	Not specified	DP and mechanical power correlated with mortality	Described as the difference between plateau pressure and PEEP	Yes	Driving pressure correlated with mortality
Goligher et al[35], 2021	Effect of lowering VT on mortality in acute respiratory distress syndrome varies with respiratory system elastance	To study the effect of lowering tidal volume on mortality in ARDS	Prospective study	Not specified	Lowering tidal volume beneficial for ARDS	Not described	Yes	Lowering tidal volume beneficial for ARDS
Costa et al[42], 2021	Ventilatory variables and mechanical power in patients with acute respiratory distress syndrome	To study ventilatory variables and mechanical power in ARDS	Prospective study	Not specified	Ventilatory variables and mechanical power associated with ARDS outcomes	Described as the difference between plateau pressure and PEEP	Yes	Ventilatory variables and mechanical power associated with ARDS outcomes

ARDS: Acute respiratory distress syndrome; PEEP: Positive end expiratory pressure; VT: Tidal volume; ICUs: Intensive care units; DP: Driving pressure.