Purpose

Personalized positive end-expiratory pressure (PEEP) might foster lung and diaphragm protection in patients with acute respiratory distress syndrome (ARDS) who are undergoing pressure support ventilation (PSV). We aimed to compare the physiologic effects of personalized PEEP set according to synchronized electrical impedance tomography (EIT) and driving transpulmonary pressure (∆PL) monitoring against a classical lower PEEP/FiO₂ table in intubated ARDS patients undergoing PSV.

Methods

A cross-over randomized multicenter study was conducted in 30 ARDS patients with simultaneous recording of the airway, esophageal and transpulmonary pressure, together with EIT during PSV. Following a decremental PEEP trial (18 cmH₂O to 4 cmH₂O), PEEP_EIT-∆PL was identified as the level with the smallest difference between lung overdistension and collapse. A low PEEP/FiO₂ table was used to select PEEP_TABLE. Each PEEP strategy was applied for 20 min, and physiologic data were collected at the end of each step.

Results

The PEEP trial was well tolerated. Median PEEP_EIT-∆PL was higher than PEEP_TABLE (10 [8–12] vs. 8 [5–10] cmH₂O; P = 0.021) and, at the individual patient level, PEEP_EIT-∆PL level differed from PEEP_TABLE in all patients. Overall, PEEP_EIT-∆PL was associated with lower dynamic ∆PL (P < 0.001) and pressure–time product (P < 0.001), but there was variability among patients. PEEP_EIT-∆PL also decreased respiratory drive and effort (P < 0.001), improved regional lung mechanics (P < 0.05) and reversed lung collapse (P = 0.007) without increasing overdistension (P = 0.695).

Conclusion

Personalized PEEP selected using synchronized EIT and transpulmonary pressure monitoring could be associated with reduced dynamic lung stress and metabolic work of breathing in ARDS patients undergoing PSV.

中文翻译：

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通过同时进行电阻抗断层扫描和跨肺压监测对急性呼吸窘迫综合征自主呼吸患者进行个性化呼气末正压测定：一项随机交叉试验

 目的

个性化呼气末正压 （PEEP） 可能会促进接受压力支持通气 （PSV） 的急性呼吸窘迫综合征 （ARDS） 患者的肺和横膈膜保护。我们旨在比较根据同步电阻抗断层扫描 （EIT） 和驾驶跨肺压 （∆PL） 监测的个性化 PEEP 设置与经典的较低 PEEP/FiO₂ 表在接受 PSV 的插管 ARDS 患者中的生理效应。

 方法

在 30 例 ARDS 患者中进行了一项交叉随机多中心研究，同时记录气道、食管和跨肺压，以及 PSV 期间的 EIT。在递减 PEEP 试验 （18 cmH₂O 至 4 cmH₂O） 之后，PEEP_EIT-∆PL 被确定为肺过度膨胀和塌陷之间差异最小的水平。使用低 PEEP/FiO₂ 表选择 PEEP_TABLE。每个 PEEP 策略应用 20 分钟，并在每个步骤结束时收集生理数据。

 结果

PEEP 试验耐受性良好。中位 PEEP_EIT-∆PL 高于 PEEP_表（10 [8-12] vs. 8 [5-10] cmH₂O;P = 0.021），并且在个体患者水平上，所有患者的 PEEP_EIT-∆PL 水平与 PEEP_TABLE 不同。总体而言，PEEP_EIT-∆PL 与较低的动态 ∆PL （P < 0.001） 和压力-时间积 （P < 0.001） 相关，但患者之间存在差异。PEEP_EIT-∆PL 还降低了呼吸驱动和努力 （P < 0.001），改善了区域肺力学 （P < 0.05） 和逆转肺塌陷 （P = 0.007），但没有增加过度膨胀 （P = 0.695）。

 结论

使用同步 EIT 和跨肺压监测选择的个性化 PEEP 可能与接受 PSV 的 ARDS 患者动态肺应激和呼吸代谢功的减少有关。