From the Guidelines
Driving pressure in mechanical ventilation is the difference between the plateau pressure and the positive end-expiratory pressure (PEEP).
Definition and Calculation
- It is calculated as ΔP = Pplat - PEEP, where Pplat is the plateau pressure and PEEP is the positive end-expiratory pressure 1.
- Driving pressure is a measure of the pressure required to inflate the lungs and is an important parameter in mechanical ventilation.
Clinical Significance
- High driving pressures have been associated with increased risk of lung injury and mortality in patients with acute respiratory distress syndrome (ARDS) 1.
- A driving pressure of more than 15 cmH2O is considered high and is associated with poor outcomes 1.
- Driving pressure is a better predictor of outcome in ARDS than either tidal volume or plateau pressure 1.
Ventilatory Strategies
- Lung-protective ventilation strategies that limit tidal volumes and driving pressures are recommended for patients with ARDS 1.
- The use of lower tidal volumes and higher PEEP levels may be necessary to maintain oxygenation and reduce driving pressure 1.
- Alveolar recruitment maneuvers and the use of positive end-expiratory pressure (PEEP) can help to reduce driving pressure and improve lung mechanics 1.
From the Research
Definition of Driving Pressure
- Driving pressure is defined as the plateau airway pressure minus positive end-expiratory pressure (PEEP) 2
- It can also be expressed as the ratio of tidal volume to respiratory system compliance, indicating the decreased functional size of the lung observed in patients with acute respiratory distress syndrome (ARDS) 2
Clinical Significance of Driving Pressure
- Driving pressure is a strong predictor of mortality in patients with ARDS, as supported by a post hoc analysis of previous randomized controlled trials and a subsequent meta-analysis 2
- A meta-analysis suggested targeting driving pressure below 13-15 cmH2O 2
- Higher driving pressure is associated with increased mortality in patients with ARDS, regardless of PEEP levels, tidal volume, or plateau pressure 3
Measurement of Driving Pressure
- Driving pressure can be measured during controlled mechanical ventilation and assisted ventilation (i.e., pressure support ventilation) 4
- Plateau pressure and respiratory system compliance can be reliably measured during pressure support ventilation in the majority of adult patients with ARDS 4
Optimization of Driving Pressure
- The use of driving pressure to optimize individually tidal volume, but not PEEP, in mechanically ventilated patients with and without ARDS is advocated 5
- Lowering driving pressure by using very low tidal volumes may improve outcomes in patients with ARDS 3
- Further large-scale clinical studies are needed to better utilize driving pressure in mechanical ventilation-requiring patients 6
Association with Outcomes
- Higher driving pressure is independently associated with increased risk of death in patients with ARDS 4
- Lower respiratory system compliance is also associated with increased mortality in patients with ARDS 4
- Driving pressure is closely associated with increased mortality in patients with ARDS, and its measurement can be used to guide ventilation strategies 2, 4