Driving pressure in mechanical ventilation: A review

Table 1 Findings from clinical studies regarding driving pressure

Population	Ref.	Study design	Sample	Findings
ARDS	Blondonnet et al[40]	Prospective cohort; secondary analysis	221 patients with at least 1 risk factor for ARDS	15% developed ARDS within 7 d who had higher baseline ΔP
ARDS	Guerin et al[7]	2 randomized controlled trials	787 patients	DP was more strongly associated with survival as compared to PEEP and tidal volume in ARDS patients
		Secondary analysis		PEEP and Tidal volume were not associated with death in any model
ARDS	Romano et al[41]	Pilot randomized, controlled, nonblinded trial	31 patients with ARDS on invasive mechanical ventilation with a driving pressure of ≥ 13 cm H2O	DP and tidal volumes were lower in the driving pressure-limited group as opposed to the conventional group, although there was no effect on outcomes
ARDS	Chiumello et al[2]	Prospective cohort	150 patients	At ICU admission, non-surviving patients had a higher arterial carbon dioxide compared to survivors; The transpulmonary driving pressure was significantly related to the airway DP; The transpulmonary driving pressure was significantly related to lung stress
ARDS	Amato et al[3]	Meta-analysis of 9 RCTs	3562 patients in the ICU	ARDS patients with elevated DP of 15cm H2O were positively associated with higher mortality; A DP of less than 15 cm H2O was a safe threshold to guide ventilation in ARDS patients and decrease mortality
ARDS	Bellani et al[27]	Prospective cohort	459 ICUs; 12906 patients	High peak pressures, higher plateau pressures, high driving pressures of > 14 cm H2O, and low peep were associated with increased mortality; There was a direct relationship between both plateau and DP and mortality
ARDS	Bellani et al[29]	Retrospective cohort study	154 patients	DP was higher, compliance was lower and peak pressure was similar, in non-survivors versus survivors; Lower respiratory system compliance and higher driving pressure were each independently associated with an increased risk of death
ARDS	Urner et al[32]	Registry-based cohort study	9 ICUs; 12865 patients requiring > 24 h of mechanical ventilation	Mortality was 18.1% with DP < 15 cm H2O compared with 20.1% under usual care
ARDS	Haudebourg et al[11]	Prospective cohort	51 adult patients	The change from PBW to ∆P-guided ventilation was thus accompanied by an overall increase in tidal volume from 6.1 mL/kg PBW to 7.7 mL/kg PBW (6.2-8.7), while the respiratory rate was decreased from 29 breaths/min to 21 breaths/min
ECMO	Gupta et al[44]	Retrospective cohort	192 patients	47% had a decrease in DP, whereas 32 46% had an increase in DP, and 7% had no change in DP after ECMO initiation. Those with an increase in DP had a significantly longer stay on ECMO than those without; Higher DP 24 h after ECMO initiation was associated with an increase in 30-d mortality
ARDS	Del Sorbo et al[47]	Randomized crossover physiologic study	10 patients	A linear relationship was seen between the change in driving pressure and the concentration of IL-6
ECMO	Magunia et al[45]	Retrospective cohort	105 patients undergoing VV-ECMO	ΔP was greater than 15 mbar in non-survivors
ECMO and ARDS	Chiu et al[46]	Retrospective cohort	158 patients with severe ARDS on ECMO	After ECMO initiation, non-survivors had significantly higher dynamic DP until day 7 than survivors; Acute Physiology and Chronic Health Evaluation II score, ARDS duration before ECMO and mean driving pressure were independently associated with mortality
Surgical	Blank et al[49]	Retrospective cohort	1019 patients undergoing thoracic surgery with ventilation	DP was a risk factor for overall post-operative morbidity
Surgical	Neto et al[50]	Meta-analysis	17 randomized controlled trials, including 2250 post-operative patients	DP was associated with the development of postoperative pulmonary complications; An increase in the level of PEEP that resulted in an increase in DP was associated with more postoperative pulmonary complications
Surgical	Mathis et al[51]	Observational Cohort	4694 patients	10.9% experienced pulmonary complications
Surgical	Park et al[52]	Double-blind, randomized, controlled trial	292 patients	Melbourne Group Scale of at least 4 occurred in 8 of 145 patients in the DP group
	Li et al[71]	Systematic review and meta-analysis	640 patients	The incidence of PPCS was lower and the compliance of the respiratory system was higher in the DP-oriented group during OLV
Obesity	De Jong et al[55]	Retrospective cohort	72% non-obese and 28% obese patients	The mortality rate at day 90 was 47% in the non-obese and 46% in the obese patients; In obese patients, driving pressure at day 1 was not significantly different
Pregnant	Lapinsky et al[60]	Prospective cohort	In 21 ICUs 69 patients requiring invasive mechanical ventilation, and 47 patients delivered while on the ventilator	Survivors had an average DP of < 14 cm H2O; Maternal mortality rate of 17.5 %, and perinatal mortality rate of 15.4%; The mortality rate was lower than in the general COVID-19 population
Pediatric	Rauf et al[9]	Retrospective cohort study	380 children in the ICU	Children in the group with low ΔP (< 15 cm H2O) had significantly lower median duration of ventilation, length of stay and ventilator-free days
ARDS	Yehya et al[61]	Prospective cohort study	544 children	DP was not an independent predictor of mortality
Pediatric	Schelven et al[13]	Prospective cohort study (secondary analysis)	222 children	Higher disease severity, MV indication, and increase in extubation time in patients with higher DPs
Heart Failure	Yang et al[67]	Retrospective cohort	632 patients	DP was independently associated with in-hospital mortality
No ARDS	Schmidt et al[10]	Retrospective cohort	622 patients	ΔP was not independently associated with hospital mortality

ARDS: Acute respiratory distress syndrome; PEEP: Positive end expiratory pressure; ICU: Intensive care unit; ΔP: Change in pressure; MV: Mechanical ventilation; DP: Driving pressure; OLV: One-lung ventilation; PPCS: Postoperative pulmonary complications; ECMO: Extracorporeal membrane oxygenation; PBW: Predicted body weight; COVID-19: Coronavirus disease 2019; RCT: Randomised controlled trials.