Abstract
BackgroundDespite their potential interest for clinical management, measurements of respiratory mechanics in patients with acute respiratory distress syndrome (ARDS) are seldom performed in routine practice. We introduced a systematic assessment of respiratory mechanics in our clinical practice. After the first year of clinical use, we retrospectively assessed whether these measurements had any influence on clinical management and physiological parameters associated with clinical outcomes by comparing their value before and after performing the test.MethodsThe respiratory mechanics assessment constituted a set of bedside measurements to determine passive lung and chest wall mechanics, response to positive end-expiratory pressure, and alveolar derecruitment. It was obtained early after ARDS diagnosis. The results were provided to the clinical team to be used at their own discretion. We compared ventilator settings and physiological variables before and after the test. The physiological endpoints were oxygenation index, dead space, and plateau and driving pressures.ResultsSixty-one consecutive patients with ARDS were enrolled. Esophageal pressure was measured in 53 patients (86.9%). In 41 patients (67.2%), ventilator settings were changed after the measurements, often by reducing positive end-expiratory pressure or by switching pressure-targeted mode to volume-targeted mode. Following changes, the oxygenation index, airway plateau, and driving pressures were significantly improved, whereas the dead-space fraction remained unchanged. The oxygenation index continued to improve in the next 48 h.ConclusionsImplementing a systematic respiratory mechanics test leads to frequent individual adaptations of ventilator settings and allows improvement in oxygenation indexes and reduction of the risk of overdistention at the same time.Trial registrationThe present study involves data from our ongoing registry for respiratory mechanics (ClinicalTrials.gov identifier: NCT02623192. Registered 30 July 2015).
Highlights
Despite their potential interest for clinical management, measurements of respiratory mechanics in patients with acute respiratory distress syndrome (ARDS) are seldom performed in routine practice
For the purpose of our retrospective study, we found that the Total positive end-expiratory pressure (PEEPtot) was not always assessed and documented by clinicians before or after the measurements and that the Airway plateau pressure (Pplat) was sometimes estimated from the Airway peak pressure (Ppeak) in patients receiving pressure-controlled ventilation (PCV)
Airway pressure (Paw)-based respiratory mechanics were measured in all patients, and an esophageal catheter was placed in 54 patients (88.5%)
Summary
Despite their potential interest for clinical management, measurements of respiratory mechanics in patients with acute respiratory distress syndrome (ARDS) are seldom performed in routine practice. We introduced a systematic assessment of respiratory mechanics in our clinical practice. Patients with acute respiratory distress syndrome (ARDS) present various degrees of impairment in respiratory mechanics and different physiological responses to a given level of positive end-expiratory pressure (PEEP). One needs to individualize the PEEP level by evaluating both its safety and its effectiveness for a specific patient [1]. This requires the assessment of gas exchange, respiratory mechanics, and hemodynamic variables. Partitioning lung and chest wall mechanics can help the individualization of ventilator settings
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