Elevated Driving Pressure in Pressure-Controlled Ventilation: An Independent Risk Factor for Adverse Outcomes in...

Driving pressure (DP) has recently gained attention as a meaningful variable in lung-protective ventilation, particularly in studies of adult acute respiratory distress syndrome. Its role in neonates, particularly regarding bronchopulmonary dysplasia (BPD), is poorly defined.

This single-center retrospective study included 145 neonates who received invasive conventional mechanical ventilation (CMV) for ≥ 72 h between January 1, 2020 and December 31, 2024. In this study, DP was obtained by subtracting the applied positive end-expiratory pressure (PEEP) from the peak inspiratory pressure(PIP), following common clinical practice in pressure-controlled ventilation. Patients were grouped into High DP (≥ 10 cmH₂O) and Low DP (< 10 cmH₂O). The primary outcome was a composite of BPD, severe intraventricular hemorrhage (IVH grade ≥ III), need for surgical intervention, or death. A subgroup analysis of preterm infants < 32 weeks with neonatal respiratory distress syndrome (NRDS) assessed DP and the Clinical Risk Index for Babies II (CRIB II) score as predictors of BPD.

The composite adverse outcome rate was higher in the High DP group than in the Low DP group (44.7 vs. 21.7%; P = 0.03), primarily driven by increased BPD incidence (25.0 vs. 8.7%; P = 0.009). Multivariate analysis identified High DP (adjusted odds ratio [aOR] = 5.30; 95% CI, 2.20-12.74) and gestational age < 32 weeks (aOR = 11.11; 95% CI, 4.35-28.36) as independent risk factors. In the NRDS subgroup (n = 61), both High DP (aOR = 5.80; 95% CI, 1.61-20.90) and higher CRIB II score (aOR = 4.44; 95% CI, 1.28-15.42) independently predicted BPD, with comparable discriminatory ability (DP AUC = 0.707; CRIB II AUC = 0.733). Lower DP was protective against progression to more severe BPD (aOR = 0.20; P = 0.008).

Elevated DP is an independent, modifiable risk factor for adverse outcomes-particularly BPD-in mechanically ventilated neonates. The effect is most pronounced in very preterm infants. Routine DP monitoring combined with clinical scoring (e.g., CRIB II) may improve early risk stratification and facilitate individualized lung-protective ventilation.