Titration of Ventilator Settings to Target Driving Pressure and Mechanical Power

BACKGROUND: Driving pressure (AP) and mechanical power (MP) may be important mediators of lung injury in ARDS; however, there is little evidence for strategies directed at reducing these pa-rameters. We applied predictive modeling to estimate the effects of modifying ventilator parameters on AP and MP. METHODS: Two thousand six hundred twenty-two subjects with ARDS (Berlin criteria) from the Medical Information Mart for Intensive Care IV version 1.0 database admit-ted to the ICU at Beth Israel Deaconess Medical Center between 2008-2019 were included. Flexible confounding-adjusted regression models for time-varying data were fit to estimate the effects of adjusting PEEP and tidal volume (VT) on AP and adjusting VT and breathing frequency on MP. RESULTS: Reduction in VT reduced AP and MP, with more pronounced effect on MP with lower compliance. Strategies reducing frequency consistently increased MP (when VT was adjusted to maintain consistent minute ventilation). Adjustment of PEEP yielded a U-shaped effect on AP. CONCLUSIONS: This novel conditional modeling confirmed expected response pat-terns for AP, with the response to adjustments depending on subjects' lung mechanics. Furthermore, a VT-driven approach should be favored over a breathing frequency-driven approach when aiming to reduce MP.