Phenotypes of esophageal pressure response to the change of positive end-expiratory pressure in patients with moderate acute respiratory distress syndrome.

Abstract

Esophageal pressure (Pes) has been used as a surrogate of pleural pressure (Ppl) to titrate positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS) patients. The relationship between Pes and PEEP remains undetermined. A gastric tube with a balloon catheter was inserted to monitor Pes in moderate to severe ARDS patients who underwent invasive mechanical ventilation. To assess the end-expiratory Pes response (ΔPes) to PEEP changes (ΔPEEP), the PEEP level was decreased and increased subsequently (with an average change of 3 cmH2O). The patients underwent the following two series of PEEP adjustment: (I) from PEEP-3 cmH2O to PEEPbaseline; and (II) from PEEPbaseline to PEEP+3 cmH2O. The patients were classified as "PEEP-dependent type" if they had ΔPes ≥30% ΔPEEP and were otherwise classified as "PEEP-independent type" (ΔPes <30% ΔPEEP in any series). In total, 54 series of PEEP adjustments were performed in 18 ARDS patients. Of these patients, 12 were classified as PEEP-dependent type, and six were classified as PEEP-independent type. During the PEEP adjustment, end-expiratory Pes changed significantly in the PEEP-dependent patients, who had a Pes of 10.8 (7.9, 12.3), 12.5 (10.5, 14.9), and 14.5 (13.1, 18.3) cmH2O at PEEP-3 cmH2O, PEEPbaseline, and PEEP+3 cmH2O, respectively (median and quartiles; P<0.0001), while end-expiratory transpulmonary pressure (PL) was maintained at an optimal range [-0.1 (-0.7, 0.4), 0.1 (-0.6, 0.5), and 0.3 (-0.3, 0.7) cmH2O, respectively]. In the PEEP-independent patients, the Pes remained unchanged, with a Pes of 15.4 (11.4, 17.8), 15.5 (11.6, 17.8), and 15.4 (11.7, 18.30) cmH2O at each of the three PEEP levels, respectively. Meanwhile, end-expiratory PL significantly improved [from -5.5 (-8.5, -3.4) at PEEP-3 cmH2O to -2.5 (-5.0, -1.6) at PEEPbaseline to -0.5 (-1.8, 0.3) at PEEP+3 cmH2O; P<0.01]. Two types of Pes phenotypes were identified according to the ΔPes to ΔPEEP. The underlying mechanisms and implications for clinical practice require further exploration.