Driving Down Mortality: A 12-Year Retrospective Cohort Analysis of Mechanical Power and Driving Pressure in Ventilated ICU Patients

Background and Objectives: Mechanical ventilation, while essential, can precipitate ventilator-induced lung injury (VILI) due to excessive mechanical stress. Among respiratory mechanics, driving pressure (ΔP) has emerged as the most robust predictor of mortality, with mechanical power (MP) and tidal volume (TV), respiratory rate (RR), positive end-expiratory pressure (PEEP), and peak inspiratory pressure (Ppeak) also potentially influencing clinical outcomes. This study primarily evaluated whether the implementation of a standardized Lung and Diaphragm Protective Ventilation (LDPV) protocol, designed to minimize ΔP, reduced intensive care unit (ICU) mortality. Secondary objectives included assessing the prognostic impact of MP, Ppeak, TV, RR, and PEEP on mortality in the pre- and post-LDPV implementation periods. Materials and Methods: In this retrospective cohort study, a total of 3468 adult ICU patients receiving invasive mechanical ventilation between 2012 and 2024 were analyzed. Patients were categorized into two groups: pre-LDPV (2012–2018) and post-LDPV (2019–2024). Ventilatory data were automatically collected using the Metavision system and evaluated through receiver operating characteristic (ROC) derived cutoffs, survival modeling, and Cox proportional hazards regression. Results: Implementation of the LDPV protocol was associated with a significant reduction in ICU mortality (47.7% vs. 41.1%, p < 0.0001) and a shorter ICU length of stay. Patients in the post-LDPV cohort (2019–2024) exhibited lower ΔP (median 12.9 vs. 14.3 cmH2O), lower MP (median 15.0 vs. 17.0 J/min), improved respiratory system compliance, and reduced peak inspiratory pressure (Ppeak) and tidal volume (TVe) compared to the pre-LDPV cohort (2012–2018). Analysis revealed that the reduction in ΔP was the most significant determinant of improved survival; median ΔP decreased by approximately 2 cmH2O (from 14.3 to 12.9 cmH2O). Elevated MP and Ppeak were also predictive of mortality, while compliance below 34 mL/cmH2O consistently indicated a poor prognosis across both study periods. Conclusions: Implementation of an LDPV protocol significantly reduced ICU mortality, primarily through the systematic reduction in ΔP, while MP and its components provided complementary prognostic information. These findings underscore ΔP as the primary modifiable determinant of survival, with MP, Ppeak, TV, and PEEP serving as secondary indicators of VILI.