Personalized positive-end expiratory pressure using electrical impedance tomography in ARDS patients: a systematic...

Personalized mechanical ventilation strategies can improve outcomes in patients with Acute Respiratory Distress Syndrome (ARDS). However, the optimal method for titrating positive end-expiratory pressure (PEEP) remains controversial. Electrical Impedance Tomography (EIT), by enabling real-time, regional assessment of lung regional characteristics, offers potential advantages to guiding PEEP titration as compared to conventional methods.

We conducted a systematic review and meta-analysis of randomized clinical trials and observational studies comparing EIT-guided versus conventional PEEP titration in adult ARDS. The review was conducted according to the PRISMA 2020 guidelines. Moreover, the review was conducted in accordance with the MOOSE (Meta-analysis of Observational Studies in Epidemiology) recommendations, where applicable, and with the registered protocol (PROSPERO ID: CRD420251015187). The primary outcomes were the PaO₂/FiO₂ ratio and respiratory system compliance (Crs). Secondary outcomes included driving pressure (ΔP), mechanical power (MP), and mortality. Random-effects meta-analysis was performed. Risk of bias and GRADE assessments were conducted using the ROB 2.0 and ROBINS-I tools, depending on the study design.

Nine studies (n = 356 patients) were included. EIT-guided PEEP titration was associated with an improvement in oxygenation, expressed as PaO₂/FiO₂ ratio, in the EIT guided PEEP group (MD + 60.81; 95% CI 30.37-91.25), with low heterogeneity. Furthermore, significant improvement in respiratory system compliance was observed in EIT guided PEEP (MD + 6.81 mL/cm H₂O; 95% CI 3.73-9.89). No statistically significant difference was observed in driving pressure between groups (MD -0.78 cm H₂O; 95% CI -1.63 to 0.07). Mechanical power showed a non-significant difference across groups (MD -0.76 J/min; 95% CI -2.30 to 0.78). Mortality did not differ between groups (risk ratio 0.88; 95% CI 0.45-1.72).

EIT-guided PEEP titration improves oxygenation and respiratory system compliance in patients with ARDS, supporting its role as a physiology-based strategy for ventilatory personalization. Further evidence are needed to determine whether these physiological improvements translate into better clinical outcomes.