Is EIT-guided positive end-expiratory pressure titration for optimizing PEEP in ARDS the white elephant in the room? A systematic review with meta-analysis and trial sequential analysis.

Electrical Impedance Tomography (EIT) is a novel real-time lung imaging technology for personalized ventilation adjustments, indicating promising results in animals and humans. The present study aimed to assess its clinical utility for improved ventilation and oxygenation compared to traditional protocols. Comprehensive electronic database screening was done until 30th November, 2023. Randomized controlled trials, controlled clinical trials, comparative cohort studies, and assessments of EIT-guided PEEP titration and conventional methods in adult ARDS patients regarding outcome, ventilatory parameters, and P/F ratio were included. Our search retrieved five controlled cohort studies and two RCTs with 515 patients and overall reduced risk of mortality [RR = 0.68; 95% CI: 0.49 to 0.95; I² = 0%], better dynamic compliance [MD = 3.46; 95% CI: 1.59 to 5.34; I² = 0%] with no significant difference in PaO₂/FiO₂ ratio [MD = 6.5; 95%CI -13.86 to 26.76; I² = 74%]. The required information size except PaO₂/FiO₂ was achieved for a power of 95% based on the 50% reduction in risk of mortality, 10% improved compliance as the cumulative Z-score of the said outcomes crossed the alpha spending boundary and did not dip below the inner wedge of futility. EIT-guided individualized PEEP titration is a novel modality; further well-designed studies are needed to substantiate its utility. Highlights: Question: Is the EIT-guided PEEP titration in ARDS universally beneficial and effective? Findings: This systematic review found better survivability, dynamic compliance, in ARDS patients, as the required information size was achieved for a power of 95%. There was no significant improvement in oxygenation and successful weaning incidence compared to conventional methods. However, the required information size for these contexts is yet to be achieved. Meaning: EIT-guided PEEP titration in ARDS patients showed promising results and warranted further clinical trials. [ABSTRACT FROM AUTHOR]