EIT-Guided PEEP Did Not Lower Mortality in ARDS Trial

Key Takeaways

• Overall 28-day mortality was similar between the randomized groups.
• Ventilator-free days, secondary clinical outcomes, safety outcomes, and first-week PEEP levels were also similar.
• The trial ended early for futility, while a higher-recruitability subgroup had lower reported mortality with EIT-guided PEEP.

Among adults with moderate to severe ARDS, a randomized trial found that EIT-guided PEEP did not significantly reduce prespecified 28-day mortality versus a classical lower PEEP/FiO2 table. Mortality at 28 days was 55.9% with EIT-guided PEEP and 52.6% with the table-based strategy. Adults with moderate to severe disease were randomized across participating sites in China during the trial period. The trial compared individualized EIT-based bedside PEEP titration with the control strategy, and the primary outcome was neutral between the two approaches.

Investigators enrolled adults with moderate to severe ARDS at five sites in China from February 2022 through June 2023 in this multicenter trial. In the intervention arm, PEEP was selected from the collapse-overdistension crossing point during a decremental PEEP trial, while the comparator group followed the classical lower PEEP/FiO2 table for bedside management. The prespecified primary outcome was 28-day mortality. The study appeared as an American Journal of Respiratory and Critical Care Medicine advance article on 23 January 2026.

A total of 190 patients were included and completed follow-up for the 28-day analysis. In the primary analysis, the hazard ratio for 28-day mortality was 0.96, with a 95% CI of 0.65 to 1.41 and P=.821. During the first 7 days, PEEP levels were close between groups, with a difference in marginal means of 0.2, SE 0.1, and P=.187. No between-group differences were found in ventilator-free days or in other reported secondary clinical and safety outcomes. Overall, the secondary outcome pattern was similar between the two groups.

Among patients with higher lung recruitability, as assessed by the recruitment-inflation ratio method, mortality was 35.6% with EIT-guided PEEP and 60.0% with the table strategy. Those rates reflected 16 of 45 patients and 27 of 45 patients, and investigators also reported higher assigned PEEP with the EIT-guided approach. The reported hazard ratio was 0.49, with a 95% CI of 0.26 to 0.91 and P=.024. In the EITVent randomized clinical trial, enrollment stopped early for futility after a preplanned interim analysis, and the authors concluded that early termination may have left the study underpowered. The overall randomized comparison remained neutral, even as a recruitability-defined subgroup signal was reported.