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

Abstract

Purpose Assessing efficacy of electrical impedance tomography (EIT) in optimizing positive end-expiratory pressure (PEEP) for acute respiratory distress syndrome (ARDS) patients to enhance respiratory system mechanics and prevent ventilator-induced lung injury (VILI), compared to traditional methods. Methods We carried out a systematic review and meta-analysis, spanning literature from January 2012 to May 2023, sourced from Scopus, PubMed, MEDLINE (Ovid), Cochrane, and LILACS, evaluated EIT-guided PEEP strategies in ARDS versus conventional methods. Thirteen studies (3 randomized, 10 non-randomized) involving 623 ARDS patients were analyzed using random-effects models for primary outcomes (respiratory mechanics and mechanical power) and secondary outcomes (PaO 2 /FiO 2 ratio, mortality, stays in intensive care unit (ICU), ventilator-free days). Results EIT-guided PEEP significantly improved lung compliance ( n = 941 cases, mean difference (MD) = 4.33, 95% confidence interval (CI) [2.94, 5.71]), reduced mechanical power ( n = 148, MD = − 1.99, 95% CI [− 3.51, − 0.47]), and lowered driving pressure ( n = 903, MD = − 1.20, 95% CI [− 2.33, − 0.07]) compared to traditional methods. Sensitivity analysis showed consistent positive effect of EIT-guided PEEP on lung compliance in randomized clinical trials vs. non-randomized studies pooled (MD) = 2.43 (95% CI − 0.39 to 5.26), indicating a trend towards improvement. A reduction in mortality rate (259 patients, relative risk (RR) = 0.64, 95% CI [0.45, 0.91]) was associated with modest improvements in compliance and driving pressure in three studies. Conclusions EIT facilitates real-time, individualized PEEP adjustments, improving respiratory system mechanics. Integration of EIT as a guiding tool in mechanical ventilation holds potential benefits in preventing ventilator-induced lung injury. Larger-scale studies are essential to validate and optimize EIT’s clinical utility in ARDS management. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-024-07362-2.

Electrical Impedance Tomography: A Narrative Review on Technology Principles and Its Current and Future Fields of Application

“…EIT represents a transformative advancement in the management of Acute Respiratory Distress Syndrome (ARDS), a condition characterized by acute hypoxemic respiratory failure and noncardiogenic pulmonary edema [12]. The complexity of ARDS, with its diverse lung injury patterns, necessitates precise, real-time imaging to guide therapeutic decisions and interventions [13,14].…”

“…EIT offers a direct view of how these interventions affect lung ventilation and perfusion in real-time. For instance, research by Songsangvorn et al has demonstrated that EIT-guided PEEP titration not only enhances lung compliance, but also reduces the mechanical power and driving pressures required, thereby potentially decreasing the incidence of ventilator-induced lung injuries (VILI) and improving overall respiratory mechanics[14,15].• Optimizing Mechanical Ventilation: EIT's ability to provide immediate feedback on lung mechanics is crucial for the fine-tuning of mechanical ventilation settings. This feedback helps clinicians balance the need for adequate oxygenation with the risk of exacerbating lung injury, thus significantly impacting patient prognosis.…”

Electrical Impedance Tomography, Artificial Intelligence, and Variable Ventilation: Transforming Respiratory Monitoring and Treatment in Critical Care

“…EIT represents a transformative advancement in the management of Acute Respiratory Distress Syndrome (ARDS), a condition characterized by acute hypoxemic respiratory failure and non-cardiogenic pulmonary edema [12]. The complexity of ARDS, with its diverse lung injury patterns, necessitates precise, real-time imaging to guide therapeutic decisions and interventions [13,14].…”

“…This capability allows clinicians to make informed decisions and adjustments based on immediate feedback from the patient's respiratory status. For example, research by Songsangvorn et al has demonstrated that EIT-guided PEEP titration can significantly enhance lung compliance [14]. By using EIT to tailor PEEP settings to the individual patient's needs, clinicians can ensure that the applied PEEP levels are neither too high, which could lead to overdistension, nor too low, which might result in insufficient alveolar recruitment.…”

Concern for meta-analysis combining randomized parallel and cross-over trials

“…I read the recent meta-analysis by Songsangvorn et al on electrical impedance tomography-guided positive endexpiratory pressure (PEEP) titration in acute respiratory distress syndrome (ARDS) with great interest [1]. While I commend the authors for their excellent work, I have some concerns regarding the meta-analysis.…”