PEEP titration in moderate to severe ARDS: plateau versus transpulmonary pressure

Bergez, M.; Fritsch, Nicolas; Tran-Van, David; Saghi, Tahar; Bounkim, Tan; Gentile, Ariane; Labadie, P; Fontaine, Bruno; Ouattara, Alexandre; Rozé, Hadrien

doi:10.1186/s13613-019-0554-3

Cited by 9 publications

(9 citation statements)

References 33 publications

(53 reference statements)

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“…Our study results showed that there was a good correlation and agreement between the measurements and there was no bias between them, but elastance derived method calculated PL significantly higher than the other two methods. These findings are in line with the results of other studies performed in patients with ARDS [ 21 , 22 ]. Inspiratory PL is an important parameter to reflect lung overdistension and PL D is the most frequently used method fort his aim.…”

Section: Discussionsupporting

confidence: 93%

Assessment of different computing methods of inspiratory transpulmonary pressure in patients with multiple mechanical problems

İnci

Boyacı

Kara

et al. 2021

J Clin Monit Comput

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While plateau airway pressure alone is an unreliable estimate of lung overdistension inspiratory transpulmonary pressure (PL) is an important parameter to reflect it in patients with ARDS and there is no concensus about which computation method should be used to calculate it. Recent studies suggest that different formulas may lead to different tidal volume and PEEP settings. The aim of this study is to compare 3 different inspiratory PL measurement method; direct measurement (PL D ), elastance derived (PL E ) and release derived (PL R ) methods in patients with multiple mechanical abnormalities. 34 patients were included in this prospective observational study. Measurements were obtained during volume controlled mechanical ventilation in sedated and paralyzed patients. During the study day airway and eosephageal pressures, flow, tidal volume were measured and elastance, inspiratory PL E , PL D and PL R were calculated. Mean age of the patients was 67 ± 15 years and APACHE II score was 27 ± 7. Most frequent diagnosis of the patients were pneumonia (71%), COPD exacerbation(56%), pleural effusion (55%) and heart failure(50%). Mean plateau pressure of the patients was 22 ± 5 cmH 2 O and mean respiratory system elastance was 36.7 ± 13 cmH 2 O/L. E L /E RS % was 0.75 ± 0.35%. Mean expiratory transpulmonary pressure was 0.54 ± 7.7 cmH 2 O (min: − 21, max: 12). Mean PL E (18 ± 9 H 2 O) was significantly higher than PL D (13 ± 9 cmH 2 O) and PL R methods (11 ± 9 cmH 2 O). There was a good aggreement and there was no bias between the measurements in Bland–Altman analysis. The estimated bias was similar between the PL D and PL E (− 3.12 ± 11 cmH 2 O) and PL E and PL R (3.9 ± 10.9 cmH 2 O) measurements. Our results suggest that standardization of calculation method of inspiratory PL is necessary before using it routinely to estimate alveolar overdistension.

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Section: Discussionsupporting

confidence: 93%

Assessment of different computing methods of inspiratory transpulmonary pressure in patients with multiple mechanical problems

İnci

Boyacı

Kara

et al. 2021

J Clin Monit Comput

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“…Possible explanations for the association of mortality with PEEP/FIO2 table non-adherence could be the deleterious pulmonary and cardiovascular effects of high PEEP. High PEEP may cause overdistension of alveoli 7 , possibly leading to biotrauma and barotrauma, though we did not observe the latter in our patients. In addition, high PEEP can increase intrathoracic pressure, impede venous return, reduce cardiac output, and cause systemic hypotension 8 .…”

Section: Discussioncontrasting

confidence: 80%

“…If the PEEP is set too low, the patient runs the risk of ventilator-induced lung injury from cyclic opening and closing of alveoli. If the PEEP is set too high, the patient runs the risk of alveolar over-distension 7 (possibly leading to barotrauma and biotrauma), and excessive intrathoracic pressure 8 (possibly leading to reduced venous return, increased right ventricular afterload and systemic hypotension).…”

Section: Introductionmentioning

confidence: 99%

Patient characteristics and outcomes associated with adherence to the low PEEP/FIO2 table for acute respiratory distress syndrome

See

Sahagun

Taculod

2021

Sci Rep

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It remains uncertain how best to set positive end-expiratory pressure (PEEP) for mechanically ventilated patients with the acute respiratory distress syndrome (ARDS). Among patients on low tidal volume ventilation (LTVV), we investigated if further adherence to the low PEEP/FIO2 (inspired oxygen fraction) table would be associated with better survival compared to nonadherence. Patients with ARDS, admitted directly from the Emergency Department to our 20-bed Medical Intensive Care Unit (ICU) from August 2016 to July 2017, were retrospectively studied. To determine adherence to the low PEEP/FIO2 table, PEEP and FIO2 12 h after ICU admission were used, to reflect ventilator adjustments by ICU clinicians after initial stabilization. Logistic regression was used to analyze hospital mortality as an outcome with adherence to the low PEEP/FIO2 as the key independent variable, adjusted for age, APACHE II score, initial P/F ratio and initial systolic blood pressure. 138 patients with ARDS were analysed. Overall adherence to the low PEEP/FIO2 table was 75.4%. Among patients on LTVV, nonadherence to the low PEEP/FIO2 table was associated with increased mortality compared to adherence (adjusted odds ratio 4.10, 95% confidence interval 1.68–9.99, P = 0.002). Patient characteristics at baseline were not associated with adherence to the low PEEP/FIO2 table.

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“…There is no consensus on how best to set PEEP to effectively stabilize lung tissue (Coruh and Luks, 2014;Gattinoni et al, 2017;Nieman et al, 2017a;Bergez et al, 2019). The current ARDSnet method for setting PEEP uses a sliding scale of oxygenation (Acute Respiratory Distress Syndrome Network, 2000), but increased oxygenation does not correlate well with an increase in alveolar stability (Andrews et al, 2015), a key VILI mechanism (Wellman et al, 2014(Wellman et al, , 2016Cereda et al, 2016bCereda et al, , 2017.…”

Section: Problems With Stabilizing the Lungmentioning

confidence: 99%

A Physiologically Informed Strategy to Effectively Open, Stabilize, and Protect the Acutely Injured Lung

et al. 2020

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Acute respiratory distress syndrome (ARDS) causes a heterogeneous lung injury and remains a serious medical problem, with one of the only treatments being supportive care in the form of mechanical ventilation. It is very difficult, however, to mechanically ventilate the heterogeneously damaged lung without causing secondary ventilatorinduced lung injury (VILI). The acutely injured lung becomes time and pressure dependent, meaning that it takes more time and pressure to open the lung, and it recollapses more quickly and at higher pressure. Current protective ventilation strategies, ARDSnet low tidal volume (LVt) and the open lung approach (OLA), have been unsuccessful at further reducing ARDS mortality. We postulate that this is because the LVt strategy is constrained to ventilating a lung with a heterogeneous mix of normal and focalized injured tissue, and the OLA, although designed to fully open and stabilize the lung, is often unsuccessful at doing so. In this review we analyzed the pathophysiology of ARDS that renders the lung susceptible to VILI. We also analyzed the alterations in alveolar and alveolar duct mechanics that occur in the acutely injured lung and discussed how these alterations are a key mechanism driving VILI. Our analysis suggests that the time component of each mechanical breath, at both inspiration and expiration, is critical to normalize alveolar mechanics and protect the lung from VILI. Animal studies and a meta-analysis have suggested that the time-controlled adaptive ventilation (TCAV) method, using the airway pressure release ventilation mode, eliminates the constraints of ventilating a lung with heterogeneous injury, since it is highly effective at opening and stabilizing the time-and pressure-dependent lung. In animal studies it has been shown that by "casting open" the acutely injured lung with TCAV we can (1) reestablish normal expiratory lung volume as assessed by direct observation of subpleural alveoli; (2) return normal parenchymal microanatomical structural support, known as alveolar interdependence and parenchymal tethering, as assessed by morphometric analysis of lung histology; (3) facilitate regeneration of normal surfactant function measured as increases in surfactant proteins A and B; and (4) significantly increase lung compliance, which reduces the pathologic impact of driving pressure and mechanical power at any given tidal volume.

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PEEP titration in moderate to severe ARDS: plateau versus transpulmonary pressure

Cited by 9 publications

References 33 publications

Assessment of different computing methods of inspiratory transpulmonary pressure in patients with multiple mechanical problems

Assessment of different computing methods of inspiratory transpulmonary pressure in patients with multiple mechanical problems

Patient characteristics and outcomes associated with adherence to the low PEEP/FIO2 table for acute respiratory distress syndrome

A Physiologically Informed Strategy to Effectively Open, Stabilize, and Protect the Acutely Injured Lung

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