Driving pressure on the ventilator in adult mechanical ventilation: the number between Pplat and PEEP

Driving pressure on the ventilator is plateau pressure minus PEEP, the pressure above the baseline it takes to deliver each tidal volume into a mechanically ventilated adult’s lungs, written ΔP. StatPearls’ EMS ventilator chapter pairs a target under 15 cm H2O with a plateau under 30 cm H2O (NBK537072). It’s measured, not set, and like every value here it’s checked against the patient, local protocol, and scope of practice.

Verify the driving pressure target: under 15 cm H2O

A commonly used driving pressure target for a mechanically ventilated adult is under 15 cm H2O, per StatPearls’ EMS ventilator chapter (NBK537072). StatPearls’ mechanical-ventilation chapter words it slightly differently, tying a ΔP that exceeds 14 to a smaller tidal volume in its lung-protective strategy (NBK539742), and a peer-reviewed review calls even 15 cm H2O only speculative, since no safe limit for ΔP has been proven (Bugedo 2017). A 2025 trial built to test limiting it directly, STAMINA, found no benefit (Maia 2025; more below). It’s not a physiologic normal, but a lung-protection target drawn from ARDS data. A plateau under the 30 ceiling can still come with a ΔP over 15: the ARDS mortality association held even at protective plateau pressures and tidal volumes (Amato 2015). The same pair of pressures frames adult lung-protective vent settings, step by step.

Is driving pressure the same as PEEP?

No. PEEP is the baseline held at end-exhalation. Driving pressure is the rise from that baseline to the plateau read on the end-inspiratory hold, not to the peak. Plateau pressure is the whole height; ΔP is the part above PEEP.

Calculate driving pressure on the ventilator: plateau minus total PEEP

Calculating driving pressure on a ventilator takes two numbers off two holds and one subtraction.

1. Passive patient, volume-control breath at the set tidal volume, no inspiratory or expiratory effort and no circuit leak, or the numbers aren’t valid (Hamilton Medical knowledge base; Amato’s “not actively breathing”).
2. End-inspiratory hold, read the top number. This page doesn’t re-teach the hold: the inspiratory hold that measures plateau pressure covers the timing and validity in full.
3. End-expiratory hold, read total PEEP, the set PEEP plus any auto-PEEP.
4. Subtract: the difference between the two readings is ΔP.

Some transport ventilators offer a plateau maneuver only as an option, and at least one displays a calculated plateau and driving pressure without a hold, which its maker says can read higher than the true value.

Total PEEP vs set PEEP

With auto-PEEP present, the pressure in the alveoli at end-exhalation sits above the dial setting. Hamilton Medical’s knowledge base defines the subtraction with total PEEP, read on its own end-expiratory hold. Merck describes the matching maneuver from the auto-PEEP side: an end-expiratory hold in a passive patient reflects alveolar pressure at the end of expiration. The table below works the arithmetic: subtracting set PEEP instead changes the number by the auto-PEEP hidden underneath it, and airway obstruction is one cause Merck names for auto-PEEP.

Driving pressure in pressure control ventilation

In pressure assist-control, the set pressure above PEEP is itself called the driving pressure (NBK539742), and StatPearls’ EMS chapter uses the same words for pressure support (NBK537072). That set number approximates a measured plateau minus PEEP only when inspiratory flow reaches zero before the breath ends (Sosio and Bellani 2019). With the patient breathing on pressure support, the number on the screen is a setting, not a measured value.

Interpret a high driving pressure: it reads compliance, not tube resistance

A high driving pressure reads compliance, not the resistance of the tube. Because it equals tidal volume divided by respiratory-system compliance (ΔP = Vt/Crs), a bigger number at the same tidal volume means stiffer lungs, and a smaller one means better compliance (Amato 2015; Bugedo 2017). Amato’s framing: compliance tracks how much aerated, functional lung is left, so the number scales the breath to the lung actually available, not a healthy adult’s. A high reading points at the same compliance causes as a high plateau: the ARDS lung itself (Amato 2015), and Merck’s list from edema and atelectasis to ascites or a tube slipped into one mainstem bronchus.

Compare what the driving pressure evidence shows in ARDS

The evidence behind that pairing comes from ARDS patients, not ventilated adults generally. Amato and colleagues’ 2015 NEJM analysis applied multilevel mediation analysis to individual data from 3,562 ARDS patients across nine randomized trials: ΔP was the ventilation variable most strongly associated with survival, and a 1-SD increment, about 7 cm H2O, was associated with a relative risk of death of 1.41. Tidal volume or PEEP changes after randomization were associated with survival only when they were among the changes that lowered it. That’s an association from a secondary analysis of trial data, not a demonstrated benefit for every ventilated adult. STAMINA, a randomized trial built to test limiting driving pressure directly, enrolled adults with moderate to severe ARDS from community-acquired pneumonia, stopped early for recruitment fatigue after 214 patients, and found no benefit: it did not increase ventilator-free days compared with a standard low-PEEP strategy (Maia 2025). The two arms’ ΔP differed by only 0.7 cm H2O up to day 3.

How do you reduce driving pressure?

Which lever fits is a judgment about this patient, this protocol, and scope of practice; the app does the tidal volume arithmetic for whichever 4 to 8 mL/kg target the clinician picks, and it doesn’t measure or compute driving pressure.

• Smaller tidal volume. StatPearls’ mechanical-ventilation chapter ties it to a smaller tidal volume, inside the 4 to 8 mL/kg range the 2017 ARDS ventilation guideline allows (NBK539742; ATS/ESICM/SCCM 2017). The tidal volume calculator with the IBW chart works out the new number from ideal body weight.
• PEEP moves it either way. In Amato’s ARDS data, PEEP changes were associated with survival only when they lowered it: an increase that recruits collapsed lung can lower it, one that overdistends already-open lung can raise it (Bugedo 2017). Titrating PEEP on scene stays protocol and scope territory, the same ground the ARDSnet protocol settings for tidal volume and PEEP cover.
• Find the compliance cause. A high reading is a symptom; the compliance causes above are the ones worth chasing.
• Hold minute ventilation with rate. A faster rate can help offset the minute ventilation a smaller breath gives up, though permissive hypercapnia may be unavoidable (NBK539742). Holding minute ventilation as the tidal volume drops works through the rest of that math.

Recheck driving pressure after each change and document it

The ARDS Network protocol card rechecks the plateau after each change in PEEP or tidal volume, and since driving pressure comes from that same reading, it gets rechecked on the same trigger. Document it alongside the PEEP in use and the tidal volume: the number means nothing on its own, without the breath and baseline that produced it. Once it’s read and in range, what it says about compliance is its own subject, and the settings it feeds back into are the pressures you verify after intubation.

Sources

1. Kuhl EA, Perera TB. Prehospital Mechanical Ventilation. In: StatPearls. StatPearls Publishing; updated March 8, 2024. https://www.ncbi.nlm.nih.gov/books/NBK537072/
2. Hickey SM, Sankari A, Giwa AO. Invasive Mechanical Ventilation. In: StatPearls. StatPearls Publishing; updated March 30, 2024. https://www.ncbi.nlm.nih.gov/books/NBK539742/
3. Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372(8):747-755. https://pubmed.ncbi.nlm.nih.gov/25693014/
4. Maia IS, Cavalcanti AB, Tramujas L, 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 Anaesth. 2025;134(3):693-702. https://pubmed.ncbi.nlm.nih.gov/39592365/
5. Bugedo G, Retamal J, Bruhn A. Driving pressure: a marker of severity, a safety limit, or a goal for mechanical ventilation? Crit Care. 2017;21:199. https://pmc.ncbi.nlm.nih.gov/articles/PMC5543756/
6. Hamilton Medical, Clinical Experts Group. How to measure driving pressure. Hamilton Medical knowledge base; first published August 30, 2017. https://www.hamilton-medical.com/en_US/Resource-center/Article-page~knowledge-base~d86f5713-a749-49ec-988f-e3403f7ca4dc~.html
7. Patel BK. Overview of Mechanical Ventilation. Merck Manual Professional Edition; updated June 2026. https://www.merckmanuals.com/professional/critical-care-medicine/respiratory-failure-and-mechanical-ventilation/overview-of-mechanical-ventilation
8. NIH NHLBI ARDS Clinical Network. Mechanical Ventilation Protocol Summary (protocol card), via University of Michigan clinical mirror. https://ecosystem.tactuum.com/university-of-michigan/respiratory/ardsnet-mechanical-ventilation-protocol/
9. Sosio S, Bellani G. Plateau pressure during pressure control ventilation. AboutOpen. 2019;6(1):76-77. https://doi.org/10.33393/abtpn.2019.297
10. Fan E, Del Sorbo L, Goligher EC, et al. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017;195(9):1253-1263. https://pubmed.ncbi.nlm.nih.gov/28459336/