The STAMINA trial was ironically named, it turns out

The STAMINA trial enrolled patients in Brazil with severe pneumonia and acute hypoxemic respiratory failure (aka ARDS), randomizing them to a dynamic strategy limiting the driving pressure (= plateau pressure minus PEEP, representing the distending pressure on the lung with each breath) or a strategy limiting PEEP.

The protocol for the intervention arm was a respiratory physiology lover’s dream come true.

Lung compliance increases with the level of PEEP applied, statrting at a lower inflection point (LIP) up to an upper inflection point (UIP) at which compliance decreases, reflecting overdistension.

In STAMINA, PEEP was individually titrated for each patient to optimize their compliance. Once their optimal PEEP was set, their tidal volumes were reduced to reduce driving pressure to the lowest level that could support adequate gas exchange.

For control arm patients, PEEP was titrated according to a low PEEP:FiO2 ARDS table (e.g., PEEP 5 for FiO2 30%, up to PEEP 18-24 for FiO2 100%).

Plateau pressure ≤30 cm H2O was targeted for all patients.

Target enrollment was 500, but STAMINA was stopped early from “recruitment fatigue” after 214 patients were enrolled.

Among the 198 available for analysis, there were no differences between groups in ventilator-free days (6 vs 7, P=0.28).

The underpowering produced an absence of evidence, rather than evidence of absence, and the possibility remains that a driving pressure-guided strategy could improve outcomes.

—Maia et al. Effect of a driving pressure-limiting strategy for patients with acute respiratory distress syndrome secondary to community-acquired pneumonia: the STAMINA randomised clinical trial -Br J Anesthesia