Low versus high positive end expiratory pressure in noninvasive ventilation for hypoxemic respiratory failure: a multicenter randomized controlled trial

Duan, J; Liu, X; Shu, W; Tian, S; Yang, M; Ma, M; Song, A; Liu, Q; Wang, K; Yang, F; Huang, T; Jiang, L; Hong, Y; Han, X; Ao, Z; Bai, L; Min, Y; Hu, W; He, J

doi:10.1007/s00134-025-07902-4

Respiratory failure & ventilation

Low versus high positive end expiratory pressure in noninvasive ventilation for hypoxemic respiratory failure: a multicenter randomized controlled trial

Intensive Care MedPublished 30 Apr 2025Randomised controlled trial

Primary result · NIV failureResultAbsolute difference 11.1 % 95% CI 1.3–20.5%

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Authors' conclusion

High PEEP during NIV may reduce treatment failure in patients with acute hypoxemic respiratory failure, although this benefit may be partially confounded by higher tidal volume observed in the low PEEP group.

Study context

Population: Hypoxemic patients receiving noninvasive ventilation (NIV) via oronasal or nasal mask, seven ICUs in Chinaintention-to-treat
Participants: 380 patients

Comparison: High positive end expiratory pressure (PEEP) vs low PEEP during NIV
High PEEPn = 190
Low PEEPn = 190reference
Primary endpoint: NIV failure (intubation, death, or therapy withdrawal [refusal of intubation despite need])

Methodological detailsmulticentre, open-label, 1:1 randomisation

Multicentre
Open-label
1:1 randomisation

Primary result

NIV failure

Absolute difference

11.1 %

95% CI 1.3–20.5%

P = 0.034

Events by treatment group

Low PEEP43%82 of 190

High PEEP32%61 of 190

Low PEEP vs High PEEP

absolute difference 11.1 % (95% CI 1.3–20.5%); P = 0.034

As reported in the abstract

Further findings

Outcome	← Lower with low PEEP ←→ Higher with low PEEP →	Difference (mL/kg predicted body weight) (95% CI)
Tidal volume · Within 72 h post-randomization	−0.500.511.5	0.8 (0.5–1.1)
	−0.500.511.5Difference, mL/kg predicted body weight (linear scale)

Outcome	← Lower with low PEEP ←→ Higher with low PEEP →	Mean difference (cmH2O) (95% CI)
Support pressure · Within 72 h post-randomization	−2024	2.9 (2.7–3.1)
	−2024Difference, cmH2O (linear scale)

Outcome	Mean difference (mmHg) (95% CI)
PaO2/FiO2 ratio · Within 72 h post-randomization	- 31 (- 38 to - 24)

Safety

Adverse events

Did not differ between the groups

Original publication

Low versus high positive end expiratory pressure in noninvasive ventilation for hypoxemic respiratory failure: a multicenter randomized controlled trial. Intensive Care Med. Published 30 April 2025. doi:10.1007/s00134-025-07902-4

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