High PEEP/low FiO₂ ventilation is associated with lower mortality in COVID–19

Rationale: The positive end–expiratory pressure (PEEP) strategy in patients with coronavirus 2019 (COVID–19) acute respiratory distress syndrome (ARDS) remains debated. Most studies originate from the initial waves of the pandemic. Here we aimed to assess the impact of high PEEP/low FiO₂ ventilation on outcomes during the second wave in the Netherlands. Methods: Retrospective observational study of invasively ventilated COVID–19 patients during the second wave. Patients were categorized based on whether they received high PEEP or low PEEP ventilation according to the ARDS Network tables. The primary outcome was ICU mortality, and secondary outcomes included hospital and 90–day mortality, duration of ventilation and length of stay, and the occurrence of kidney injury. Propensity matching was performed to correct for factors with a known relationship to ICU mortality. Results: This analysis included 790 COVID–ARDS patients. At ICU discharge, 32 (22.5%) out of 142 high PEEP patients and 254 (39.2%) out of 848 low PEEP patients had died (HR 0.66 [0.46–0.96]; P = 0.03). High PEEP was linked to improved secondary outcomes. Matched analysis did not change findings. Conclusions: High PEEP ventilation was associated with improved ICU survival in patients with COVID–ARDS.