Positive-end expiratory pressure titration and transpulmonary pressure: the EPVENT 2 trial

Turbil, Emanuele; Galerneau, Louis Marie; Terzi, Nicolas; Schwebel, Carole; Argaud, Laurent; Guérin, Claude

doi:10.21037/jtd.2019.06.34

Cited by 5 publications

(4 citation statements)

References 28 publications

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“…Esophageal pressure guided PEEP titration has been evaluated in two trials [447,448]. While the pilot study suggested benefit [448], the subsequent 200 patient multicentre RCT that compared PEEP titration guided by esophageal (P ES ) measurement versus empirical high PEEP-FiO 2 titration, showed no significant difference in a composite outcome of death and days free from mechanical ventilation through day 28 [449]. There are limited data on ventilation strategies for patients with sepsis-induced respiratory failure who do not meet criteria for ARDS.…”

Section: Rationalementioning

confidence: 99%

Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021

et al. 2021

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Section: Rationalementioning

confidence: 99%

Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021

et al. 2021

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“…Esophageal pressure guided PEEP titration has been evaluated in two trials (447, 448). While the pilot study suggested benefit (448), the subsequent 200 patient multicenter RCT that compared PEEP titration guided by esophageal (P ES ) measurement versus empirical high PEEP-FiO 2 titration, showed no significant difference in a composite outcome of death and days free from mechanical ventilation through day 28 (449).…”

Section: Screening and Early Treatmentmentioning

confidence: 99%

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021

Evans

Rhodes

Alhazzani

et al. 2021

Critical Care Medicine

1,327

1,081

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shock (27). The specific components of performance improvement did not appear to be as important as the presence of a program that included sepsis screening and metrics.Sepsis screening tools are designed to promote early identification of sepsis and consist of manual methods or automated use of the electronic health record (EHR). There is wide variation in diagnostic accuracy of these tools with most having poor predictive values, although the use of some was associated with improvements in care processes (28)(29)(30)(31). A variety of clinical variables and tools are used for sepsis screening, such as systemic inflammatory response syndrome (SIRS) criteria, vital signs, signs of infection, quick Sequential Organ Failure Score (qSOFA) or Sequential Organ Failure Assessment (SOFA) criteria, National Early Warning Score (NEWS), or Modified Early Warning Score (MEWS) (26,32). Machine learning may improve performance of screening tools, and in a meta-analysis of 42,623 patients from seven studies for predicting hospital acquired sepsis the pooled area under the receiving operating curve (SAUROC) (0.89; 95% CI, 0.86−0.92); sensitivity (81%; 95% CI, 80−81), and specificity (72%; 95% CI, 72−72) was higher for machine learning than the SAUROC for traditional screening tools such as SIRS (0.70), MEWS (0.50), and SOFA (0.78) (32).Screening tools may target patients in various locations, such as in-patient wards, emergency departments, or ICUs (28)(29)(30)32). A pooled analysis of three RCTs did not demonstrate a mortality benefit of active screening (RR, 0.90; 95% CI, 0.51−1.58) (33-35). However, while there is wide variation in sensitivity and specificity of sepsis screening tools, they are an important component of identifying sepsis early for timely intervention.Standard operating procedures are a set of practices that specify a preferred response to specific clinical circumstances (36). Sepsis standard operating procedures, initially specified as Early Goal Directed Therapy have evolved to "usual care" which includes a standard approach with components of the sepsis bundle, early identification, lactate, cultures, antibiotics, and fluids (37). A large study examined the association between implementation of state-mandated sepsis protocols, compliance, and mortality. A retrospective cohort study of 1,012,410 sepsis admissions to 509 hospitals in the United States in a retrospective cohort examined mortality before (27 months) and after (30 months) implementation of New York state sepsis regulations, with a concurrent control population from four other states (38). In this comparative interrupted time series, mortality was lower in hospitals with higher compliance with achieving the sepsis bundles successfully.Lower resource countries may experience a different effect. A meta-analysis of two RCTs in Sub-Saharan Africa found higher mortality (RR, 1.26; 95% CI, 1.00−1.58) with standard operating procedures compared with usual care, while it was decreased in one observational study (adjusted hazard ratio [HR]; 95% CI, 0.55...

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“…The larger multicentre EPVent-2 trial (n=200, composite primary end-point incorporating mortality and ventilator-free days at day 28) did not find clinical benefits of targeting positive end-expiratory P L of 0-6 cmH 2 O compared with empirical high PEEP (high PEEP-F IO 2 table) [43]. The fact that PEEP and P plat between groups were similar during the first week and higher compared with other ARDS trials [44], and that P oes -guided PEEP setting resulted in rather high end-expiratory P L , could have contributed to the discrepancy with EPVent-1 results. Recent post-hoc reanalysis of EPVent-2 suggested better survival with P oes -guided PEEP in patients having lower Acute Physiology and Chronic Health Evaluation (APACHE) II score (less severe multiple organ failure) and that benefits could be maximised by targeting end-expiratory P L tightly within 0±2 cmH 2 O compared with higher or more negative values [45].…”

Section: Artefactsmentioning

confidence: 91%

The oesophageal balloon for respiratory monitoring in ventilated patients: updated clinical review and practical aspects

et al. 2023

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There is a well-recognised importance for personalising mechanical ventilation settings to protect the lungs and the diaphragm for each individual patient. Measurement of oesophageal pressure (Poes) as an estimate of pleural pressure allows assessment of partitioned respiratory mechanics and quantification of lung stress, which helps our understanding of the patient's respiratory physiology and could guide individualisation of ventilator settings. Oesophageal manometry also allows breathing effort quantification, which could contribute to improving settings during assisted ventilation and mechanical ventilation weaning. In parallel with technological improvements,Poesmonitoring is now available for daily clinical practice. This review provides a fundamental understanding of the relevant physiological concepts that can be assessed usingPoesmeasurements, both during spontaneous breathing and mechanical ventilation. We also present a practical approach for implementing oesophageal manometry at the bedside. While more clinical data are awaited to confirm the benefits ofPoes-guided mechanical ventilation and to determine optimal targets under different conditions, we discuss potential practical approaches, including positive end-expiratory pressure setting in controlled ventilation and assessment of inspiratory effort during assisted modes.

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Positive-end expiratory pressure titration and transpulmonary pressure: the EPVENT 2 trial

Cited by 5 publications

References 28 publications

Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021

Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021

The oesophageal balloon for respiratory monitoring in ventilated patients: updated clinical review and practical aspects

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