Abstract
Introduction: The best way to titrate the positive end-expiratory pressure (PEEP) in patients suffering from acute respiratory distress syndrome is still matter of debate. Electrical impedance tomography (EIT) is a non-invasive technique that could guide PEEP setting based on an optimized ventilation homogeneity.Methods: For this study, we enrolled the patients with 2019 coronavirus disease (COVID-19)-related acute respiratory distress syndrome (ARDS), who required mechanical ventilation and were admitted to the ICU in March 2021. Patients were monitored by an esophageal catheter and a 32-electrode EIT device. Within 48 h after the start of mechanical ventilation, different levels of PEEP were applied based upon PEEP/FiO2 tables, positive end-expiratory transpulmonary (PL)/ FiO2 table, and EIT. Respiratory mechanics variables were recorded.Results: Seventeen patients were enrolled. PEEP values derived from EIT (PEEPEIT) were different from those based upon other techniques and has poor in-between agreement. The PEEPEIT was associated with lower plateau pressure, mechanical power, transpulmonary pressures, and with a higher static compliance (Crs) and homogeneity of ventilation.Conclusion: Personalized PEEP setting derived from EIT may help to achieve a more homogenous distribution of ventilation. Whether this approach may translate in outcome improvement remains to be investigated.
Highlights
The best way to titrate the positive end-expiratory pressure (PEEP) in patients suffering from acute respiratory distress syndrome is still matter of debate
We describe a case series of patients suffering from 2019 coronavirus disease (COVID-19)-related acute respiratory distress syndrome (ARDS) in whom we compared PEEP settings based on PEEP/FiO2 tables, PL/ FiO2 table, and Electrical impedance tomography (EIT)
Positive end-expiratory pressure derived from EIT (PEEPEIT), corresponding to the lowest level of PEEP achieving the lowest percentage of total silent spaces, was significantly different from the other PEEP values
Summary
The best way to titrate the positive end-expiratory pressure (PEEP) in patients suffering from acute respiratory distress syndrome is still matter of debate. The “right” PEEP should allow for optimized lung recruitment while minimizing over-distention To this aim, clinicians can use PEEP-FiO2 tables [2], transpulmonary pressure (PL) [3], or electrical impedance tomography (EIT). The transpulmonary pressure is measured using an esophageal balloon catheter that approximates the pleural pressure Using this technique, PEEP has to be set to maintain the end-expiratory PL above zero to avoid collapse of dependent dorsal lung regions, and the end-inspiratory PL below 20–25 cmH2O to decrease the risk of overdistension of non-dependent regions. Regional hypoventilated lung units (“Silent spaces”) correspond to both collapsed areas in the dependent territories, and distended areas in the non-dependent regions Using this technique, PEEP is set to minimize the percentage of total silent spaces
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