What is the evidence for driving pressure as a ventilation target?

Amato et al. (NEJM 2015): among 3562 ARDS patients, driving pressure (DP = Pplat minus PEEP) was the single variable most strongly associated with survival - each 1 cmH2O increase in DP increases mortality risk 1.41x. DP <=14 cmH2O is protective. DP represents the tidal stretch of aerated lung - normalizes VT for functional lung size (baby lung concept).

How should tidal volume be adjusted to achieve target driving pressure?

Start with VT 6 mL/kg IBW. If Pplat >30 cmH2O or DP >15 cmH2O: reduce VT by 1 mL/kg steps to minimum 4 mL/kg IBW. Accept permissive hypercapnia (pH >7.20). If DP still >15 at 4 mL/kg: consider increasing PEEP (which may reduce DP if lung is recruitable) or prone positioning (increases recruitable lung). Never increase VT to correct hypercapnia if DP >15.

Driving Pressure Limit in ARDSnet Ventilation

Calculate driving pressure (plateau pressure minus PEEP) and target <=14 to 15 cmH2O to minimize ventilator-induced lung injury in ARDS. Adjust tidal volume and PEEP to achieve target driving pressure.

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Frequently Asked Questions

What is the evidence for driving pressure as a ventilation target?

How should tidal volume be adjusted to achieve target driving pressure?