Abstract
BackgroundThe application of positive end-expiratory pressure (PEEP) may reduce dynamic strain during mechanical ventilation. Although numerous approaches for PEEP titration have been proposed, there is no accepted strategy for titrating optimal PEEP. By analyzing intratidal compliance profiles, PEEP may be individually titrated for patients.MethodsAfter obtaining informed consent, 60 consecutive patients undergoing general anesthesia were randomly allocated to mechanical ventilation with PEEP 5 cmH2O (control group) or PEEP individually titrated, guided by an analysis of the intratidal compliance profile (intervention group). The primary endpoint was the frequency of each nonlinear intratidal compliance (CRS) profile of the respiratory system (horizontal, increasing, decreasing, and mixed). The secondary endpoints measured were respiratory mechanics, hemodynamic variables, and regional ventilation, which was assessed via electrical impedance tomography.ResultsThe frequencies of the CRS profiles were comparable between the groups. Besides PEEP [control: 5.0 (0.0), intervention: 5.8 (1.1) cmH2O, p < 0.001], the respiratory and hemodynamic variables were comparable between the two groups. The compliance profile analysis showed no significant differences between the two groups. The loss of ventral and dorsal regional ventilation was higher in the control [ventral: 41.0 (16.3)%; dorsal: 25.9 (13.8)%] than in the intervention group [ventral: 29.3 (17.6)%; dorsal: 16.4 (12.7)%; p (ventral) = 0.039, p (dorsal) = 0.028].ConclusionsUnfavorable compliance profiles indicating tidal derecruitment were found less often than in earlier studies. Individualized PEEP titration resulted in slightly higher PEEP. A slight global increase in aeration associated with this was indicated by regional gain and loss analysis. Differences in dorsal to ventral ventilation distribution were not found.Trial registrationThis clinical trial was registered at the German Register for Clinical Trials (DRKS00008924) on August 10, 2015.
Highlights
The application of positive end-expiratory pressure (PEEP) may reduce dynamic strain during mechanical ventilation
To evaluate the intratidal Compliance of the respiratory system (CRS) with the enhanced gliding-SLICE method, the pressure-volume curve is subdivided into several volume steps, and the volume-dependent compliance is calculated on the base of data points within a certain volume range (‘slice’) around the current step via multiple linear regression analysis (Fig. 1)
In this study, we compared the effects of individualized PEEP titration performed according to bedside analysis of the frequencies of nonlinear intratidal CRS profiles
Summary
The application of positive end-expiratory pressure (PEEP) may reduce dynamic strain during mechanical ventilation. It is widely accepted that the application of low tidal volume and low driving pressure, i.e., the difference between plateau pressure (PPlat) and (positive) end-expiratory pressure (PEEP), protects the lung from the destructive effects of alveolar overdistension [1,2,3,4]. First described in 1979 for patients with severe lung injury [9], is based on setting the PEEP slightly above the lower inflection point of the inspiratory limb of the static pressure-volume curve [5, 10, 11]. To evaluate the intratidal CRS with the enhanced gliding-SLICE method, the pressure-volume curve is subdivided into several volume steps, and the volume-dependent compliance is calculated on the base of data points within a certain volume range (‘slice’) around the current step via multiple linear regression analysis (Fig. 1). A decreasing compliance profile indicates overdistension, suggesting a PEEP decrease
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