TY - JOUR
T1 - Personalized Positive End-Expiratory Pressure in Acute Respiratory Distress Syndrome
T2 - Comparison between Optimal Distribution of Regional Ventilation and Positive Transpulmonary Pressure
AU - Scaramuzzo, Gaetano
AU - Spadaro, Savino
AU - Dalla Corte, Francesca
AU - Waldmann, Andreas D.
AU - Böhm, Stephan H.
AU - Ragazzi, Riccardo
AU - Marangoni, Elisabetta
AU - Grasselli, Giacomo
AU - Pesenti, Antonio
AU - Volta, Carlo Alberto
AU - Mauri, Tommaso
PY - 2020
Y1 - 2020
N2 - Objectives: Different techniques exist to select personalized positive end-expiratory pressure in patients affected by the acute respiratory distress syndrome. The positive end-expiratory transpulmonary pressure strategy aims to counteract dorsal lung collapse, whereas electrical impedance tomography could guide positive end-expiratory pressure selection based on optimal homogeneity of ventilation distribution. We compared the physiologic effects of positive end-expiratory pressure guided by electrical impedance tomography versus transpulmonary pressure in patients affected by acute respiratory distress syndrome. Design: Cross-over prospective physiologic study. Setting: Two academic ICUs. Patients: Twenty ICU patients affected by acute respiratory distress syndrome undergoing mechanical ventilation. Intervention: Patients monitored by an esophageal catheter and a 32-electrode electrical impedance tomography monitor underwent two positive end-expiratory pressure titration trials by randomized cross-over design to find the level of positive end-expiratory pressure associated with: 1) positive end-expiratory transpulmonary pressure (PEEPPL) and 2) proportion of poorly or nonventilated lung units (Silent Spaces) less than or equal to 15% (PEEPEIT). Each positive end-expiratory pressure level was maintained for 20 minutes, and afterward, lung mechanics, gas exchange, and electrical impedance tomography data were collected. Measurements and Main Results: PEEPEIT and PEEPPL differed in all patients, and there was no correlation between the levels identified by the two methods (Rs = 0.25; p = 0.29). PEEPEIT determined a more homogeneous distribution of ventilation with a lower percentage of dependent Silent Spaces (p = 0.02), whereas PEEPPL was characterized by lower airway - but not transpulmonary - driving pressure (p = 0.04). PEEPEIT was significantly higher than PEEPPL in subjects with extrapulmonary acute respiratory distress syndrome (p = 0.006), whereas the opposite was true for pulmonary acute respiratory distress syndrome (p = 0.03). Conclusions: Personalized positive end-expiratory pressure levels selected by electrical impedance tomography- and transpulmonary pressure-based methods are not correlated at the individual patient level. PEEPPL is associated with lower dynamic stress, whereas PEEPEIT may help to optimize lung recruitment and homogeneity of ventilation. The underlying etiology of acute respiratory distress syndrome could deeply influence results from each method.
AB - Objectives: Different techniques exist to select personalized positive end-expiratory pressure in patients affected by the acute respiratory distress syndrome. The positive end-expiratory transpulmonary pressure strategy aims to counteract dorsal lung collapse, whereas electrical impedance tomography could guide positive end-expiratory pressure selection based on optimal homogeneity of ventilation distribution. We compared the physiologic effects of positive end-expiratory pressure guided by electrical impedance tomography versus transpulmonary pressure in patients affected by acute respiratory distress syndrome. Design: Cross-over prospective physiologic study. Setting: Two academic ICUs. Patients: Twenty ICU patients affected by acute respiratory distress syndrome undergoing mechanical ventilation. Intervention: Patients monitored by an esophageal catheter and a 32-electrode electrical impedance tomography monitor underwent two positive end-expiratory pressure titration trials by randomized cross-over design to find the level of positive end-expiratory pressure associated with: 1) positive end-expiratory transpulmonary pressure (PEEPPL) and 2) proportion of poorly or nonventilated lung units (Silent Spaces) less than or equal to 15% (PEEPEIT). Each positive end-expiratory pressure level was maintained for 20 minutes, and afterward, lung mechanics, gas exchange, and electrical impedance tomography data were collected. Measurements and Main Results: PEEPEIT and PEEPPL differed in all patients, and there was no correlation between the levels identified by the two methods (Rs = 0.25; p = 0.29). PEEPEIT determined a more homogeneous distribution of ventilation with a lower percentage of dependent Silent Spaces (p = 0.02), whereas PEEPPL was characterized by lower airway - but not transpulmonary - driving pressure (p = 0.04). PEEPEIT was significantly higher than PEEPPL in subjects with extrapulmonary acute respiratory distress syndrome (p = 0.006), whereas the opposite was true for pulmonary acute respiratory distress syndrome (p = 0.03). Conclusions: Personalized positive end-expiratory pressure levels selected by electrical impedance tomography- and transpulmonary pressure-based methods are not correlated at the individual patient level. PEEPPL is associated with lower dynamic stress, whereas PEEPEIT may help to optimize lung recruitment and homogeneity of ventilation. The underlying etiology of acute respiratory distress syndrome could deeply influence results from each method.
KW - acute respiratory distress syndrome
KW - electrical impedance tomography
KW - positive end-expiratory pressure
KW - precision medicine
KW - transpulmonary pressure
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U2 - 10.1097/CCM.0000000000004439
DO - 10.1097/CCM.0000000000004439
M3 - Article
C2 - 32568857
AN - SCOPUS:85088461641
VL - 48
SP - 1148
EP - 1156
JO - Critical Care Medicine
JF - Critical Care Medicine
SN - 0090-3493
IS - 8
ER -