Effect of external PEEP in patients under controlled mechanical ventilation with an auto-PEEP of 5 cmH2O or higher

Natalini, Giuseppe; Tuzzo, Daniele; Rosanò, Antonio; Testa, Marco; Grazioli, Michele; Pennestrì, Vincenzo; Amodeo, Guido; Berruto, Francesco; Fiorillo, Marialinda; Peratoner, Alberto; Tinnirello, Andrea; Filippini, Matteo; Marsilia, Paolo Francesco; Minelli, Cosetta; Bernardini, Achille

doi:10.1186/s13613-016-0158-0

Cited by 15 publications

(22 citation statements)

References 28 publications

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“…In a mixed population of COPD patients and patients with acute respiratory failure, when there was expiratory flow limitation, the higher external PEEP significantly reduced the intrinsic PEEP, which was “absorbed” in the total PEEP. In contrast, in patients without expiratory flow limitation, the intrinsic PEEP did not change and the total PEEP could be increased [12, 48].…”

Section: Discussionmentioning

confidence: 99%

Dynamic hyperinflation and intrinsic positive end-expiratory pressure in ARDS patients

et al. 2019

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BackgroundIn ARDS patients, changes in respiratory mechanical properties and ventilatory settings can cause incomplete lung deflation at end-expiration. Both can promote dynamic hyperinflation and intrinsic positive end-expiratory pressure (PEEP). The aim of this study was to investigate, in a large population of ARDS patients, the presence of intrinsic PEEP, possible associated factors (patients’ characteristics and ventilator settings), and the effects of two different external PEEP levels on the intrinsic PEEP.MethodsWe made a secondary analysis of published data. Patients were ventilated with a tidal volume of 6–8 mL/kg of predicted body weight, sedated, and paralyzed. After a recruitment maneuver, a PEEP trial was run at 5 and 15 cmH2O, and partitioned mechanics measurements were collected after 20 min of stabilization. Lung computed tomography scans were taken at 5 and 45 cmH2O. Patients were classified into two groups according to whether or not they had intrinsic PEEP at the end of an expiratory pause.ResultsWe enrolled 217 sedated, paralyzed patients: 87 (40%) had intrinsic PEEP with a median of 1.1 [1.0–2.3] cmH2O at 5 cmH2O of PEEP. The intrinsic PEEP significantly decreased with higher PEEP (1.1 [1.0–2.3] vs 0.6 [0.0–1.0] cmH2O; p < 0.001). The applied tidal volume was significantly lower (480 [430–540] vs 520 [445–600] mL at 5 cmH2O of PEEP; 480 [430–540] vs 510 [430–590] mL at 15 cmH2O) in patients with intrinsic PEEP, while the respiratory rate was significantly higher (18 [15–20] vs 15 [13–19] bpm at 5 cmH2O of PEEP; 18 [15–20] vs 15 [13–19] bpm at 15 cmH2O). At both PEEP levels, the total airway resistance and compliance of the respiratory system were not different in patients with and without intrinsic PEEP. The total lung gas volume and lung recruitability were also not different between patients with and without intrinsic PEEP (respectively 961 [701–1535] vs 973 [659–1433] mL and 15 [0–32] % vs 22 [0–36] %).ConclusionsIn sedated, paralyzed ARDS patients without a known obstructive disease, the amount of intrinsic PEEP during lung-protective ventilation is negligible and does not influence respiratory mechanical properties.

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Section: Discussionmentioning

confidence: 99%

Dynamic hyperinflation and intrinsic positive end-expiratory pressure in ARDS patients

et al. 2019

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“…Application of extrinsic PEEP might eliminate the EFL by counteracting the pleural pressure at the choke point, which improves air-trapping and reduces patient's work of breathing 29,30 . This concept is supported by Natalini et al 29 study, which demonstrated that the extrinsic PEEP could abolish the auto PEEP.…”

Section: Discussionmentioning

confidence: 99%

“…Noticeably, 60% of the patients with unsuccessful extubation had EFL 9,28 . Previous studies showed that positive end expiratory pressure (PEEP) 29,30 , upright position 31 , bronchodilator 32 , and diuretics 33 possibly improved extubation outcomes in the patients with EFL.…”

Section: Introductionmentioning

confidence: 99%

Comparison of Success Rate of Extubation Between Spontaneous Breathing Trial with Pressure Support Ventilation and T-piece in Patients with Expiratory Flow Limitation

Kluanwan

Kongpolprom

2021

Preprint

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Background: Expiratory flow limitation (EFL) is an inability to exceed a certain flow regardless of the pressure exerted, which appears in 60% of patients with extubation failure. However, an appropriate weaning method for the patients with EFL remains unknown. Objectives: We aimed to evaluate an effect of different techniques of spontaneous breathing trials (SBT) on a success rate of extubation in the patients with EFL. Methods: We conducted a non-inferiority randomized controlled trial comparing between 30-minute pressure support ventilation (PSV) and 30-minute T-piece in ventilated patients with EFL who got ready to wean. The primary outcome was successful extubation during a 72-hour post-extubation period. Secondary outcomes were a reintubation rate within 7 days, time to reintubation, and a SBT success rate. Results: A total of 99 ventilated patients with EFL consisting of male (50.5%) with the median age of 70 [23] years were recruited. The most common cause of acute respiratory failure was intrapulmonary cause (68.7%). The eligible patients were randomized into 2 groups with a ratio of 1:1. The success rate of extubation during the 72-hour period in the PSV group was non-inferior to the T-piece group: 82% and 81.63%, respectively (95%CI -0.148 to 0.156, p=0.0475). There was also non-inferiority in the reintubation rate within 7 days (22.9% in the PSV group VS 15.2% in the T-piece group; 95%CI -0.081 to 0.235, p=0.005) and the SBT success rate (96% in the PSV group VS 93.9% in the T-piece group; 95%CI -0.065 to 0.108, p<0.001). There was no significant difference in the median time to reintubation between these 2 groups (55 [95.5] hours in PSV VS 25.33 [48] hours in the T-piece group, p=0.683). Conclusions: Among patients with EFL, the 30-minute SBT with PSV was non-inferior to the T-piece SBT in terms of the successful extubation during the 72-hour period, successful SBT, and reintubation rate within 7 days. This was the first study demonstrating that the different techniques of SBT did not affect the weaning outcomes in the patients with EFL.

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“…However, the presence of EFL has been previously demonstrated in other patients so that it could be hypothesised that an unknown amount of ICU patients other than COPD can exhibit EFL. This could have relevant clinical consequences since the presence of EFL has numerous side effects [1], such as the presence of PEEPi [32] that might have detrimental effects on respiratory efficiency and cardiovascular function. Further, the reduction of the expiratory flow and the inability to increase it by the expiratory muscle contraction decrease the efficacy of cough and secretion removal [14] favouring the development of atelectasis, bronchitis and pneumonia.…”

Section: Discussionmentioning

confidence: 99%

Expiratory flow limitation in intensive care: prevalence and risk factors

et al. 2019

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BackgroundExpiratory flow limitation (EFL) is characterised by a markedly reduced expiratory flow insensitive to the expiratory driving pressure. The presence of EFL can influence the respiratory and cardiovascular function and damage the small airways; its occurrence has been demonstrated in different diseases, such as COPD, asthma, obesity, cardiac failure, ARDS, and cystic fibrosis. Our aim was to evaluate the prevalence of EFL in patients requiring mechanical ventilation for acute respiratory failure and to determine the main clinical characteristics, the risk factors and clinical outcome associated with the presence of EFL.MethodsPatients admitted to the intensive care unit (ICU) with an expected length of mechanical ventilation of 72 h were enrolled in this prospective, observational study. Patients were evaluated, within 24 h from ICU admission and for at least 72 h, in terms of respiratory mechanics, presence of EFL through the PEEP test, daily fluid balance and followed for outcome measurements.ResultsAmong the 121 patients enrolled, 37 (31%) exhibited EFL upon admission. Flow-limited patients had higher BMI, history of pulmonary or heart disease, worse respiratory dyspnoea score, higher intrinsic positive end-expiratory pressure, flow and additional resistance. Over the course of the initial 72 h of mechanical ventilation, additional 21 patients (17%) developed EFL. New onset EFL was associated with a more positive cumulative fluid balance at day 3 (103.3 ml/kg) compared to that of patients without EFL (65.8 ml/kg). Flow-limited patients had longer duration of mechanical ventilation, longer ICU length of stay and higher in-ICU mortality.ConclusionsEFL is common among ICU patients and correlates with adverse outcomes. The major determinant for developing EFL in patients during the first 3 days of their ICU stay is a positive fluid balance. Further studies are needed to assess if a restrictive fluid therapy might be associated with a lower incidence of EFL.

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Effect of external PEEP in patients under controlled mechanical ventilation with an auto-PEEP of 5 cmH2O or higher

Cited by 15 publications

References 28 publications

Dynamic hyperinflation and intrinsic positive end-expiratory pressure in ARDS patients

Dynamic hyperinflation and intrinsic positive end-expiratory pressure in ARDS patients

Comparison of Success Rate of Extubation Between Spontaneous Breathing Trial with Pressure Support Ventilation and T-piece in Patients with Expiratory Flow Limitation

Expiratory flow limitation in intensive care: prevalence and risk factors

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