Electric impedance tomography-guided PEEP titration reduces mechanical power in ARDS: a randomized crossover pilot trial

Abstract

Background In patients with acute respiratory distress syndrome undergoing mechanical ventilation, positive end-expiratory pressure (PEEP) can lead to recruitment or overdistension. Current strategies utilized for PEEP titration do not permit the distinction. Electric impedance tomography (EIT) detects and quantifies the presence of both collapse and overdistension. We investigated whether using EIT-guided PEEP titration leads to decreased mechanical power compared to high-PEEP/FiO2 tables. Methods A single-center, randomized crossover pilot trial comparing EIT-guided PEEP selection versus PEEP selection using the High-PEEP/FiO2 table in patients with moderate–severe acute respiratory distress syndrome. The primary outcome was the change in mechanical power after each PEEP selection strategy. Secondary outcomes included changes in the 4 × driving pressure + respiratory rate (4 ΔP, + RR index) index, driving pressure, plateau pressure, PaO2/FiO2 ratio, and static compliance. Results EIT was consistently associated with a decrease in mechanical power compared to PEEP/FiO2 tables (mean difference − 4.36 J/min, 95% CI − 6.7, − 1.95, p = 0.002) and led to lower values in the 4ΔP + RR index (− 11.42 J/min, 95% CI − 19.01, − 3.82, p = 0.007) mainly driven by a decrease in the elastic–dynamic power (− 1.61 J/min, − 2.99, − 0.22, p = 0.027). The elastic–static and resistive powers were unchanged. Similarly, EIT led to a statistically significant change in set PEEP (− 2 cmH2O, p = 0.046), driving pressure, (− 2.92 cmH2O, p = 0.003), peak pressure (− 6.25 cmH2O, p = 0.003), plateau pressure (− 4.53 cmH2O, p = 0.006), and static respiratory system compliance (+ 7.93 ml/cmH2O, p = 0.008). Conclusions In patients with moderate–severe acute respiratory distress syndrome, EIT-guided PEEP titration reduces mechanical power mainly through a reduction in elastic–dynamic power. Trial registration This trial was prospectively registered on Clinicaltrials.gov (NCT 03793842) on January 4th, 2019.

Electrical impedance tomography-guided positive end-expiratory pressure titration in ARDS: a systematic review and meta-analysis

“…Tidal volume administration varied across the studies. Ten studies [ 36 – 38 , 41 – 47 ] utilized tidal volumes ranging from 6 to 8 ml/kg predicted body weight (PBW), while 2 studies [ 35 , 40 ] used tidal volumes of 4–6 ml/kg PBW. Additionally, 1 study [ 39 ] utilized tidal volumes of 3–4 ml/kg PBW (Table 1 ).…”

“…In the control groups of the included trials, PEEP was titrated using PEEP/FiO 2 tables in 7 studies [ 36 – 38 , 41 – 43 , 47 ], PV curves in 2 studies [ 40 , 45 ], end-expiratory transpulmonary sliding table in 2 studies [ 42 , 44 ], and physician-set PEEP or clinical PEEP in 3 studies [ 35 , 39 , 46 ].…”

Association of Mechanical Energy and Power with Postoperative Pulmonary Complications in Lung Resection Surgery: A Post Hoc Analysis of Randomized Clinical Trial Data

“…A variety of approaches have been demonstrated to successfully reduce MP delivered to the respiratory system. 45,[47][48][49] Reducing total cumulative ME could also incorporate the additional approach of reducing ventilation time. Though perhaps more difficult, particularly for anesthesiologists, there is significant interest in and data relating to reducing surgical duration.…”

Setting positive end-expiratory pressure by using electrical impedance tomography

“…The authors proposed that the latter method might be of value during assisted ventilation. A small clinical study demonstrated that the individualized PEEP derived from the decremental PEEP trial reduced the mechanical power compared with the high PEEP/F I O 2 table [19]. Another small clinical study titrated PEEP in prone and supine ARDS patients with larger relative overdistension in the prone and larger collapse in the supine position [20].…”