High vs low positive end-expiratory pressure in IMV may impact survival

A high positive end-expiratory pressure (PEEP) is likely preferred over a low PEEP in patients with acute heart failure (HF) receiving invasive mechanical ventilation (IMV). The low PEEP was associated with higher rates of in-hospital mortality and adverse events, and so the trial was terminated early.

“The clinical implications of PEEP during IMV have not been thoroughly investigated,” stated Dr Min-Seok Kim (Asan Medical Centre, South Korea) [1]. The HELP-AHF trial (NCT04853563) aimed to evaluate high and low PEEP in patients with acute HF who were in need of IMV. Participants were randomised 1:1 to high PEEP, starting at 8 cmH₂O and increasing to 10 cmH₂O, or low PEEP, starting at 5 cmH₂O and lowered to 3 cmH₂O. The study’s primary endpoint was ventilator-free days at 28 days of follow-up.

“The study was terminated early after enrolling 60 participants, due to a significant imbalance in in-hospital mortality and adverse events between the study arms,” said Dr Kim. In-hospital mortality was more frequently observed in participants in the low PEEP arm (20.7% vs 0.0%; P=0.02). There were also significantly more adverse events in the low PEEP group than in the high PEEP group (41.4% vs 6.7%; P=0.002), including higher rates of severe hypoxaemia, weaning failure, and tracheostomy. At the time of trial termination, ventilator-free days were more common in the high PEEP arm than in the low PEEP arm (25.5 vs 24.0; P=0.02).

Although the sample size of the HELP-AHF study was small, it appears that the high PEEP strategy leads to better health outcomes than the low PEEP strategy in this patient population.

1. Kim M-S, et al. Comparison of high versus low positive end-expiratory pressure in mechanically ventilated patients with acute heart failure: a HELP-AHF randomised clinical trial. Hottest trials and trial updates (2), Heart Failure 2025, 17–20 May, Belgrade, Serbia.

Medical writing support was provided by Robert van den Heuvel.
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Posted on 21 May 202517 July 2025