Abstract
BackgroundIndividualized positive end-expiratory pressure (PEEP) by electrical impedance tomography (EIT) has potential interest in the optimization of ventilation distribution in acute respiratory distress syndrome (ARDS). The aim of the study was to determine whether early individualized titration of PEEP with EIT improved outcomes in patients with ARDS.MethodsA total of 117 ARDS patients receiving mechanical ventilation were randomly assigned to EIT group (n = 61, PEEP adjusted based on ventilation distribution) or control group (n = 56, low PEEP/FiO2 table). The primary outcome was 28-day mortality. Secondary and exploratory outcomes were ventilator-free days, length of ICU stay, incidence of pneumothorax and barotrauma, and difference in Sequential Organ Failure Assessment (SOFA) score at day 1 (ΔD1-SOFA) and day 2 (ΔD2-SOFA) compared with baseline.Measurements and main resultsThere was no statistical difference in the value of PEEP between the EIT group and control group, but the combination of PEEP and FiO2 was different between groups. In the control group, a significantly positive correlation was found between the PEEP value and the corresponding FiO2 (r = 0.47, p < 0.00001) since a given matched table was used for PEEP settings. Diverse combinations of PEEP and FiO2 were found in the EIT group (r = 0.05, p = 0.68). There was no significant difference in mortality rate (21% vs. 27%, EIT vs. control, p = 0.63), ICU length of stay (13.0 (7.0, 25.0) vs 10.0 (7.0, 14.8), median (25th–75th percentile); p = 0.17), and ventilator-free days at day 28 (14.0 (2.0, 23.0) vs 19.0 (0.0, 24.0), p = 0.55) between the two groups. The incidence of new barotrauma was zero. Compared with control group, significantly lower ΔD1-SOFA and ΔD2-SOFA were found in the EIT group (p < 0.001) in a post hoc comparison. Moreover, the EIT group exhibited a significant decrease of SOFA at day 2 compared with baseline (paired t-test, difference by − 1 (− 3.5, 0), p = 0.001). However, the control group did show a similar decrease (difference by 1 (− 2, 2), p = 0.131).ConclusionOur study showed a 6% absolute decrease in mortality in the EIT group: a statistically non-significant, but clinically non-negligible result. This result along with the showed improvement in organ function might justify further reserach to validate the beneficial effect of individualized EIT-guided PEEP setting on clinical outcomes of patients with ARDS.Trial registration: ClinicalTrials, NCT02361398. Registered 11 February 2015—prospectively registered, https://clinicaltrials.gov/show/NCT02361398.
Highlights
Positive end-expiratory pressure (PEEP) is often used in acute respiratory distress syndrome (ARDS) with the aim to open collapsed lung regions and keep the lung open
Our study showed a 6% absolute decrease in mortality in the electrical impedance tomography (EIT) group: a statistically non-significant, but clinically non-negligible result
This result along with the showed improvement in organ function might justify further reserach to validate the beneficial effect of individualized EIT-guided positive end-expiratory pressure (PEEP) setting on clinical outcomes of patients with ARDS
Summary
Positive end-expiratory pressure (PEEP) is often used in acute respiratory distress syndrome (ARDS) with the aim to open collapsed lung regions and keep the lung open. EIT could provide deep insights into regional ventilation and lung mechanics allowing an individualized PEEP for ARDS patients under mechanical ventilation. Since ARDS patients have a highly variable lung recruitability, an individualized PEEP would be desirable. Individualized positive end-expiratory pressure (PEEP) by electrical impedance tomography (EIT) has potential interest in the optimization of ventilation distribution in acute respiratory distress syndrome (ARDS).
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