Technology-Enhanced Strategies to Optimize Positive End-Expiratory Pressure in Patients Receiving Invasive Mechanical Ventilation: A Systematic Review and Meta-Analysis

Objectives: To undertake a systematic review evaluating the clinical and cost-effectiveness of technology-enhanced positive end-expiratory pressure (PEEP) optimization strategies in adults and children receiving invasive mechanical ventilation on an ICU. Data Sources: We searched key electronic databases (including MEDLINE and Embase) from inception to July 2024. Study Selection: We included randomized studies examining clinical or cost-effectiveness of technology-enhanced PEEP optimization strategies compared with standard care or an alternative PEEP optimization strategy in adults and children. The primary outcome was duration of mechanical ventilation and secondary outcomes were clinical effectiveness (e.g., mortality) and efficacy (e.g., PEEP). Data Extraction: Two reviewers independently assessed eligibility, extracted data, assessed risk of bias (Revised Cochrane tool) and performed Grading of Recommendations Assessment, Development and Evaluation evidence certainty assessments. Data Synthesis: Our database and trial register search retrieved 8845 results, of which 34 studies (2951 patients) were included. Eight studies were at low risk of bias. Across studies, 7 technologies were evaluated, most commonly esophageal balloon measurement of transpulmonary pressure (10 studies), electrical impedance tomography (7 studies), pressure-volume curve analysis (6 studies), and fully automated closed-loop ventilation (5 studies). Meta-analysis used random-effects models. Duration of mechanical ventilation was reported in only three studies (172 patients, two technologies) and there was no effect compared with standard care (mean difference –0.06 d; 95% CI, –0.20 to 0.09; very low-certainty evidence). For 28-day mortality (10 studies; 1,719 patients; six technologies), technology-enhanced PEEP optimization reduced 28-day mortality (risk ratio 0.69; 95% CI, 0.52–0.93; very low-certainty evidence). No significant differences were found for other clinical-effectiveness outcomes. We identified no evidence in children or on cost-effectiveness. Conclusions: Technology-enhanced PEEP optimization strategies did not reduce duration of mechanical ventilation, but these technologies may reduce mortality. Evidence certainty was low or very low, highlighting the urgent need for adequately powered randomized trials. Registration: PROSPERO (CRD42024555390).