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Bello G, Giammatteo V, Bisanti A, Delle Cese L, Rosà T, Menga LS, Montini L, Michi T, Spinazzola G, De Pascale G, Pennisi MA, Ribeiro De Santis Santiago R, Berra L, Antonelli M, Grieco DL. High vs Low PEEP in Patients With ARDS Exhibiting Intense Inspiratory Effort During Assisted Ventilation: A Randomized Crossover Trial. Chest 2024; 165:1392-1405. [PMID: 38295949 DOI: 10.1016/j.chest.2024.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Positive end-expiratory pressure (PEEP) can potentially modulate inspiratory effort (ΔPes), which is the major determinant of self-inflicted lung injury. RESEARCH QUESTION Does high PEEP reduce ΔPes in patients with moderate-to-severe ARDS on assisted ventilation? STUDY DESIGN AND METHODS Sixteen patients with Pao2/Fio2 ≤ 200 mm Hg and ΔPes ≥ 10 cm H2O underwent a randomized sequence of four ventilator settings: PEEP = 5 cm H2O or PEEP = 15 cm H2O + synchronous (pressure support ventilation [PSV]) or asynchronous (pressure-controlled intermittent mandatory ventilation [PC-IMV]) inspiratory assistance. ΔPes and respiratory system, lung, and chest wall mechanics were assessed with esophageal manometry and occlusions. PEEP-induced alveolar recruitment and overinflation, lung dynamic strain, and tidal volume distribution were assessed with electrical impedance tomography. RESULTS ΔPes was not systematically different at high vs low PEEP (pressure support ventilation: median, 20 cm H2O; interquartile range (IQR), 15-24 cm H2O vs median, 15 cm H2O; IQR, 13-23 cm H2O; P = .24; pressure-controlled intermittent mandatory ventilation: median, 20; IQR, 18-23 vs median, 19; IQR, 17-25; P = .67, respectively). Similarly, respiratory system and transpulmonary driving pressures, tidal volume, lung/chest wall mechanics, and pendelluft extent were not different between study phases. High PEEP resulted in lower or higher ΔPes, respiratory system driving pressure, and transpulmonary driving pressure according to whether this increased or decreased respiratory system compliance (r = -0.85, P < .001; r = -0.75, P < .001; r = -0.80, P < .001, respectively). PEEP-induced changes in respiratory system compliance were driven by its lung component and were dependent on the extent of PEEP-induced alveolar overinflation (r = -0.66, P = .006). High PEEP caused variable recruitment and systematic redistribution of tidal volume toward dorsal lung regions, thereby reducing dynamic strain in ventral areas (pressure support ventilation: median, 0.49; IQR, 0.37-0.83 vs median, 0.96; IQR, 0.62-1.56; P = .003; pressure-controlled intermittent mandatory ventilation: median, 0.65; IQR, 0.42-1.31 vs median, 1.14; IQR, 0.79-1.52; P = .002). All results were consistent during synchronous and asynchronous inspiratory assistance. INTERPRETATION The impact of high PEEP on ΔPes and lung stress is interindividually variable according to different effects on the respiratory system and lung compliance resulting from alveolar overinflation. High PEEP may help mitigate the risk of self-inflicted lung injury solely if it increases lung/respiratory system compliance. TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT04241874; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Giuseppe Bello
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Valentina Giammatteo
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Harvard University, Boston, MA
| | - Alessandra Bisanti
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Luca Delle Cese
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Tommaso Rosà
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Luca S Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Luca Montini
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Giorgia Spinazzola
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Mariano Alberto Pennisi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Roberta Ribeiro De Santis Santiago
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Harvard University, Boston, MA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Harvard University, Boston, MA
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy.
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Cammarota G, Vaschetto R, Vetrugno L, Maggiore SM. Monitoring lung recruitment. Curr Opin Crit Care 2024; 30:268-274. [PMID: 38690956 DOI: 10.1097/mcc.0000000000001157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
PURPOSE OF REVIEW This review explores lung recruitment monitoring, covering techniques, challenges, and future perspectives. RECENT FINDINGS Various methodologies, including respiratory system mechanics evaluation, arterial bold gases (ABGs) analysis, lung imaging, and esophageal pressure (Pes) measurement are employed to assess lung recruitment. In support to ABGs analysis, the assessment of respiratory mechanics with hysteresis and recruitment-to-inflation ratio has the potential to evaluate lung recruitment and enhance mechanical ventilation setting. Lung imaging tools, such as computed tomography scanning, lung ultrasound, and electrical impedance tomography (EIT) confirm their utility in following lung recruitment with the advantage of radiation-free and repeatable application at the bedside for sonography and EIT. Pes enables the assessment of dorsal lung tendency to collapse through end-expiratory transpulmonary pressure. Despite their value, these methodologies may require an elevated expertise in their application and data interpretation. However, the information obtained by these methods may be conveyed to build machine learning and artificial intelligence algorithms aimed at improving the clinical decision-making process. SUMMARY Monitoring lung recruitment is a crucial component of managing patients with severe lung conditions, within the framework of a personalized ventilatory strategy. Although challenges persist, emerging technologies offer promise for a personalized approach to care in the future.
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Affiliation(s)
- Gianmaria Cammarota
- Department of Translational Medicine, Università del Piemonte Orientale, Novara
| | - Rosanna Vaschetto
- Department of Translational Medicine, Università del Piemonte Orientale, Novara
| | - Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences
| | - Salvatore M Maggiore
- Department of Anesthesiology and Intensive Care, Ospedale SS Annunziata & Department of Innovative Technologies in Medicine and Odonto-stomatology, Università Gabriele D'Annunzio di Chieti-Pescara, Chieti, Italy
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Menga LS, Subirà C, Wong A, Sousa M, Brochard LJ. Setting positive end-expiratory pressure: does the 'best compliance' concept really work? Curr Opin Crit Care 2024; 30:20-27. [PMID: 38085857 DOI: 10.1097/mcc.0000000000001121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
PURPOSE OF REVIEW Determining the optimal positive end-expiratory pressure (PEEP) setting remains a central yet debated issue in the management of acute respiratory distress syndrome (ARDS).The 'best compliance' strategy set the PEEP to coincide with the peak respiratory system compliance (or 2 cmH 2 O higher) during a decremental PEEP trial, but evidence is conflicting. RECENT FINDINGS The physiological rationale that best compliance is always representative of functional residual capacity and recruitment has raised serious concerns about its efficacy and safety, due to its association with increased 28-day all-cause mortality in a randomized clinical trial in ARDS patients.Moreover, compliance measurement was shown to underestimate the effects of overdistension, and neglect intra-tidal recruitment, airway closure, and the interaction between lung and chest wall mechanics, especially in obese patients. In response to these concerns, alternative approaches such as recruitment-to-inflation ratio, the nitrogen wash-in/wash-out technique, and electrical impedance tomography (EIT) are gaining attention to assess recruitment and overdistention more reliably and precisely. SUMMARY The traditional 'best compliance' strategy for determining optimal PEEP settings in ARDS carries risks and overlooks some key physiological aspects. The advent of new technologies and methods presents more reliable strategies to assess recruitment and overdistention, facilitating personalized approaches to PEEP optimization.
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Affiliation(s)
- Luca S Menga
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
- Università Cattolica del Sacro Cuore, Facoltà di Medicina e Chirurgia, Anesthesiology and Intensive Care Medicine
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Anesthesia, Emergency and Intensive Care Medicine, Roma, Italy
| | - Carles Subirà
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid
- Critical Care Department, Althaia Xarxa Assistencial Universitària de Manresa, IRIS Research Institute, Manresa, Spain
- Grup de Recerca de Malalt Crític (GMC). Institut de Recerca Biomèdica Catalunya Central IRIS-CC
| | - Alfred Wong
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Mayson Sousa
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Laurent J Brochard
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
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