Driving Pressure as a Primary Ventilator Target

Introduction to Driving Pressure

Driving pressure (ΔP = plateau pressure - PEEP) should be maintained ≤15 cmH₂O as it predicts mortality better than tidal volume or plateau pressure alone in mechanically ventilated patients, and represents the functional lung stress applied to the "baby lung" available for ventilation in ARDS 1, 2

Driving pressure reflects the ratio of tidal volume to respiratory system compliance, which indicates the actual "functional" size of the lung available for ventilation rather than predicted body weight 1, 2
In ARDS patients, the proportion of aerated lung is markedly decreased, making driving pressure a superior predictor of outcomes compared to tidal volume or plateau pressure measured independently 1, 3
Values exceeding 15 cmH₂O are associated with significantly increased mortality risk 1, 2

Calculate driving pressure at the bedside: ΔP = plateau pressure - PEEP 1, 2
Measure plateau pressure during an inspiratory hold maneuver (requires sedation/paralysis for accuracy) 1
If ΔP >15 cmH₂O, immediate adjustment is required 1, 2

Decrease tidal volume below 6 ml/kg PBW if necessary to achieve ΔP ≤15 cmH₂O 1, 2
Increase PEEP to recruit collapsed alveoli and improve respiratory system compliance 1, 2
For moderate-severe ARDS (PaO₂/FiO₂ <200), higher PEEP strategies reduce mortality (adjusted RR 0.90) 4

Low driving pressure may allow relaxation of strict tidal volume targets in patients with conflicting priorities (e.g., severe acidosis requiring higher minute ventilation) 1, 2
Driving pressure ≥18 cmH₂O is specifically associated with right ventricular failure risk in ARDS patients, compounding hemodynamic instability 5

Maintain plateau pressure ≤30 cmH₂O as an absolute ceiling regardless of driving pressure 1, 6
Continue targeting tidal volumes 4-8 ml/kg PBW as the foundation of lung protection 3, 6
For severe ARDS with persistent ΔP >15 cmH₂O despite optimization, consider prone positioning >12 hours/day (reduces mortality with RR 0.74) 3 or ECMO for refractory cases 5

In adult ARDS patients, a driving pressure (ΔP) > 15 cmH₂O is linked to a markedly higher risk of death, and ΔP ≥ 18 cmH₂O is specifically associated with right‑ventricular failure. 7

When ΔP is maintained at ≤15 cmH₂O, clinicians may relax the strict 6 mL/kg predicted body weight tidal‑volume limit (e.g., to accommodate severe acidosis) provided the driving pressure remains within the safe range. 7

Delivering the same tidal volume with either volume‑controlled or pressure‑controlled ventilation does not result in a difference in mortality among ARDS patients. 7

Routine recruitment maneuvers performed without documented lung recruitability do not reduce mortality and may cause harm, therefore they should be avoided. 7