Effects of peep on lung injury, pulmonary function, systemic circulation and mortality in animals with uninjured lungs—a systematic review

It is well-known that positive end-expiratory pressure (PEEP) can prevent ventilator-induced lung injury (VILI) and improve pulmonary physiology in animals with injured lungs. It’s uncertain whether PEEP has similar effects in animals with uninjured lungs. A systematic review of randomized controlled trials (RCTs) comparing different PEEP levels in animals with uninjured lungs was performed. Trials in animals with injured lungs were excluded, as were trials that compared ventilation strategies that also differed with respect to other ventilation settings, e.g., tidal volume size. The search identified ten eligible trials in 284 animals, including rodents and small as well as large mammals. Duration of ventilation was highly variable, from 1 to 6 hours and tidal volume size varied from 7 to 60 mL/kg. PEEP ranged from 3 to 20 cmH₂O, and from 0 to 5 cmH₂O, in the ‘high PEEP’ or ‘PEEP’ arms, and in the ‘low PEEP’ or ‘no PEEP’ arms, respectively. Definitions used for lung injury were quite diverse, as were other outcome measures. The effects of PEEP, at any level, on lung injury was not straightforward, with some trials showing less injury with ‘high PEEP’ or ‘PEEP’ and other trials showing no benefit. In most trials, ‘high PEEP’ or ‘PEEP’ was associated with improved respiratory system compliance, and better oxygen parameters. However, ‘high PEEP’ or ‘PEEP’ was also associated with occurrence of hypotension, a reduction in cardiac output, or development of hyperlactatemia. There were no differences in mortality. The number of trials comparing ‘high PEEP’ or ‘PEEP’ with ‘low PEEP’ or ‘no PEEP’ in animals with uninjured lungs is limited, and results are difficult to compare. Based on findings of this systematic review it’s uncertain whether PEEP, at any level, truly prevents lung injury, while most trials suggest potential harmful effects on the systemic circulation.