Bedside selection of positive end-expiratory pressure in mild, moderate, and severe acute respiratory distress syndrome

Davide Chiumello, Massimo Cressoni, Eleonora Carlesso, Maria L. Caspani, Antonella Marino, Elisabetta Gallazzi, Pietro Caironi, Marco Lazzerini, Onnen Moerer, Michael Quintel, Luciano Gattinoni

Research output: Contribution to journalArticlepeer-review

Abstract

OBJECTIVE:: Positive end-expiratory pressure exerts its effects keeping open at end-expiration previously collapsed areas of the lung; consequently, higher positive end-expiratory pressure should be limited to patients with high recruitability. We aimed to determine which bedside method would provide positive end-expiratory pressure better related to lung recruitability. DESIGN:: Prospective study performed between 2008 and 2011. SETTING:: Two university hospitals (Italy and Germany). PATIENTS:: Fifty-one patients with acute respiratory distress syndrome. INTERVENTIONS:: Whole lung CT scans were taken in static conditions at 5 and 45 cm H2O during an end-expiratory/end-inspiratory pause to measure lung recruitability. To select individual positive end-expiratory pressure, we applied bedside methods based on lung mechanics (ExPress, stress index), esophageal pressure, and oxygenation (higher positive end-expiratory pressure table of lung open ventilation study). MEASUREMENTS AND MAIN RESULTS:: Patients were classified in mild, moderate and severe acute respiratory distress syndrome. Positive end-expiratory pressure levels selected by the ExPress, stress index, and absolute esophageal pressures methods were unrelated with lung recruitability, whereas positive end-expiratory pressure levels selected by the lung open ventilation method showed a weak relationship with lung recruitability (r = 0.29; p <0.0001). When patients were classified according to the acute respiratory distress syndrome Berlin definition, the lung open ventilation method was the only one which gave lower positive end-expiratory pressure levels in mild and moderate acute respiratory distress syndrome compared with severe acute respiratory distress syndrome (8 ± 2 and 11 ± 3 cm H2O vs 15 ± 3 cm H2O; p <0.05), whereas ExPress, stress index, and esophageal pressure methods gave similar positive end-expiratory pressure values in mild, moderate, and severe acute respiratory distress syndrome. The positive end-expiratory pressure selected by the different methods were unrelated to each other with the exception of the two methods based on lung mechanics (ExPress and stress index). CONCLUSIONS:: Bedside positive end-expiratory pressure selection methods based on lung mechanics or absolute esophageal pressures provide positive end-expiratory pressure levels unrelated to lung recruitability and similar in mild, moderate, and severe acute respiratory distress syndrome, whereas the oxygenation-based method provided positive end-expiratory pressure levels related with lung recruitability progressively increasing from mild to moderate and severe acute respiratory distress syndrome.

Original languageEnglish
Pages (from-to)252-264
Number of pages13
JournalCritical Care Medicine
Volume42
Issue number2
DOIs
Publication statusPublished - Feb 2014

Keywords

  • Acute Respiratory Distress Syndrome
  • Lung
  • Lung Collapse
  • Positive End-Expiratory Pressure
  • Positive-Pressure Respiration
  • Respiratory Mechanics

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Medicine(all)

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