Study Reference
Urner M, Jüni P, Rojas-Saunero LP, et al. Limiting dynamic driving pressure in patients requiring mechanical ventilation. Crit Care Med 2023;51(7):861–871.
Brief Summary for Clinicians
What This Study Found
This large study from Toronto analyzed 12,865 mechanically ventilated patients to determine if actively limiting driving pressure (rather than just monitoring it) could save lives. They used advanced statistical methods to simulate what would happen if hospitals consistently kept driving pressure low.
Key Findings
Limiting dynamic driving pressure ≤15 cm H₂O was associated with reduced mortality:
- Usual care mortality: 20.1%
- Limited driving pressure mortality: 18.1%
- Potential benefit: 1 life per 53 patients treated (1.9% absolute reduction)
Timing appears to matter:
- Early intervention (starting day 1) showed greater benefit than delayed intervention
- Sustained intervention throughout mechanical ventilation was associated with better outcomes
- Late interventions (starting day 5 or 14) showed diminishing benefits
Dynamic vs. Static driving pressure:
- Both showed similar associations, but dynamic ΔP is easier to measure in clinical practice
- Dynamic ΔP is available on all modern ventilators regardless of mode
- Static ΔP requires plateau pressure measurements, which are difficult during spontaneous breathing
What Didn’t Show Benefit
Limiting tidal volume or peak pressures alone (without considering driving pressure) showed no mortality benefit – this suggests that driving pressure specifically may be important, not just these other parameters.
Clinical Implications
- Your driving pressure measurements may have prognostic value – this data suggests these measurements could be more meaningful than just routine documentation
- Consider driving pressure as a potential target – the data suggests aiming to keep it ≤15 cm Hâ‚‚O when feasible may be beneficial
- Dynamic ΔP (Peak – PEEP) may be your practical tool since it works in all ventilator modes and with spontaneous breathing
- Early intervention may be more effective – addressing high driving pressures sooner rather than later may be important
- This would work in addition to traditional lung-protective ventilation (low tidal volumes, appropriate PEEP)
Important limitation: This was an observational study using statistical modeling, not a randomized controlled trial, so causation cannot be definitively established. However, the findings suggest that actively managing the driving pressure values you measure daily may be worth considering as a strategy to potentially improve patient outcomes.
Reference
Urner M, Jüni P, Rojas-Saunero LP, et al. Limiting dynamic driving pressure in patients requiring mechanical ventilation. Crit Care Med 2023;51(7):861–871.
Thanks for this interesting post!
I would like to highlight that dynamic DP should never completely replace static measurements, especially in spontaneus breathing with elevated effort of breathing, as the plateau might be much higher than Ppeak in such case, which would mean a risk for P-SILI.
If dynamic DP is being taken into consideration on the equation there is a risk for those patients who have intrinsic PEEP.
Was this taken into consideration?
Also I agree some patients may have a higher Pplat on a spontaneous mode and we might be underserving the alveoli. Now not all ventilators do an inspiratory hold on PS/CPAP. One can try PC SIMV in those circumstances with a RR 2 and match your PS settings (worth a try)
Don’t have access to the full article, but the recommendation to limit the dynamic driving pressure to <15 (peak-peep) seems unclear. How do you achieve that on VC-AC? Didn’t know that dynamic driving pressure had entered into the vocab. Knew of driving pressure, Pplat-peep as static driving pressure or just driving pressure