Background
Although lung protection with low tidal volume and limited plateau pressure (
P
plat
) improves survival in acute respiratory distress syndrome patients (ARDS), the best way to set positive end-expiratory pressure (PEEP) is still debated.
Methods
This study aimed to compare two strategies using individual PEEP based on a maximum
P
plat
(28–30 cmH
2
O, the Express group) or on keeping end-expiratory transpulmonary pressure positive (0–5 cmH
2
O,
P
Lexpi
group). We estimated alveolar recruitment (Vrec), end-expiratory lung volume and alveolar distension based on elastance-related end-inspiratory transpulmonary pressure (
P
L,EL
).
Results
Nineteen patients with moderate to severe ARDS (PaO
2
/FiO
2
< 150 mmHg) were included with a baseline PEEP of 7.0 ± 1.8 cmH
2
O and a PaO
2
/FiO
2
of 91.2 ± 31.2 mmHg. PEEP and oxygenation increased significantly from baseline with both protocols; PEEP Express group was 14.2 ± 3.6 cmH
2
O versus 16.7 ± 5.9 cmH
2
O in
P
Lexpi
group. No patient had the same PEEP with the two protocols. Vrec was higher with the latter protocol (299 [0 to 875] vs. 222 [47 to 483] ml,
p
= 0.049) and correlated with improved oxygenation (
R
2
= 0.45,
p
= 0.002). Two and seven patients in the Express and
P
L,expi
groups, respectively, had
P
L,EL
> 25 cmH
2
O.
Conclusions
There is a great heterogeneity of
P
Lexpi
when
P
plat
is used to titrate PEEP but with limited risk of over-distension. A PEEP titration for a moderate positive level of
P
Lexpi
might slightly improve alveolar recruitment and oxygenation but increases the risk of over-distension in one-third of patients.
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