Abstract

BackgroundHigh respiratory drive in mechanically ventilated patients with spontaneous breathing effort may cause excessive lung stress and strain and muscle loading. Therefore, it is important to have a reliable estimate of respiratory effort to guarantee lung and diaphragm protective mechanical ventilation. Recently, a novel non-invasive method was found to detect excessive dynamic transpulmonary driving pressure (∆PL) and respiratory muscle pressure (Pmus) with reasonable accuracy. During the Coronavirus disease 2019 (COVID-19) pandemic, it was impossible to obtain the gold standard for respiratory effort, esophageal manometry, in every patient. Therefore, we investigated whether this novel non-invasive method could also be applied in COVID-19 patients.Methods∆PL and Pmus were derived from esophageal manometry in COVID-19 patients. In addition, ∆PL and Pmus were computed from the occlusion pressure (∆Pocc) obtained during an expiratory occlusion maneuver. Measured and computed ∆PL and Pmus were compared and discriminative performance for excessive ∆PL and Pmus was assessed. The relation between occlusion pressure and respiratory effort was also assessed.ResultsThirteen patients were included. Patients had a low dynamic lung compliance [24 (20–31) mL/cmH2O], high ∆PL (25 ± 6 cmH2O) and high Pmus (16 ± 7 cmH2O). Low agreement was found between measured and computed ∆PL and Pmus. Excessive ∆PL > 20 cmH2O and Pmus > 15 cmH2O were accurately detected (area under the receiver operating curve (AUROC) 1.00 [95% confidence interval (CI), 1.00–1.00], sensitivity 100% (95% CI, 72–100%) and specificity 100% (95% CI, 16–100%) and AUROC 0.98 (95% CI, 0.90–1.00), sensitivity 100% (95% CI, 54–100%) and specificity 86% (95% CI, 42–100%), respectively). Respiratory effort calculated per minute was highly correlated with ∆Pocc (for esophageal pressure time product per minute (PTPes/min) r2 = 0.73; P = 0.0002 and work of breathing (WOB) r2 = 0.85; P < 0.0001).Conclusions∆PL and Pmus can be computed from an expiratory occlusion maneuver and can predict excessive ∆PL and Pmus in patients with COVID-19 with high accuracy.

Highlights

  • High respiratory drive in mechanically ventilated patients with spontaneous breathing effort may cause excessive lung stress and strain and muscle loading

  • Computed ∆(Dynamic) transpulmonary driving pressure (PL) and pressure generated by the respiratory muscles (Pmus) are unreliable for direct estimates of ∆PL and Pmus derived from esophageal manometry, as analysis showed poor agreement between computed and measured values

  • The occlusion pressure is highly correlated with respiratory effort per minute

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Summary

Introduction

High respiratory drive in mechanically ventilated patients with spontaneous breathing effort may cause excessive lung stress and strain and muscle loading. It is important to have a reliable estimate of respiratory effort to guarantee lung and diaphragm protective mechanical ventilation. Too high respiratory effort may lead to excessive lung stress and strain causing lung injury on one hand. It may lead to excessive muscle loading causing muscle injury High respiratory drive and effort frequently exist in critically ill patients, mainly due to insufficient ventilator assistance and sedation, but evidence suggests biological predisposition (e.g., pulmonary and systemic inflammation, lung mechanical heterogeneity) plays a role as well. It is important to have a reliable estimate of respiratory effort to enable lung and diaphragm protective mechanical ventilation [6,7,8]

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