Evaluation of Positive End-Expiratory Pressure Strategies in Patients With Coronavirus Disease 2019–Induced Acute Respiratory Distress Syndrome

Abstract

Background: Different positive end-expiratory pressure (PEEP) strategies are available for subjects with coronavirus disease 2019 (COVID-19)–induced acute respiratory distress syndrome (ARDS) requiring invasive mechanical ventilation. We aimed to evaluate three conventional PEEP strategies on their effects on respiratory mechanics, gas exchanges, and hemodynamics.Methods: This is a prospective, physiologic, multicenter study conducted in China. We recruited 20 intubated subjects with ARDS and confirmed COVID-19. We first set PEEP by the ARDSnet low PEEP–fraction of inspired oxygen (FIO2) table. After a recruitment maneuver, PEEP was set at 15, 10, and 5 cm H2O for 10 min, respectively. Among these three PEEP levels, best-compliance PEEP was the one providing the highest respiratory system compliance; best-oxygenation PEEP was the one providing the highest PaO2 (partial pressure of arterial oxygen)/FIO2.Results: At each PEEP level, we assessed respiratory mechanics, arterial blood gas, and hemodynamics. Among three PEEP levels, plateau pressure, driving pressure, mechanical power, and blood pressure improved with lower PEEP. The ARDSnet low PEEP–FIO2 table and the best-oxygenation strategies provided higher PEEP than the best-compliance strategy (11 ± 6 cm H2O vs. 11 ± 3 cm H2O vs. 6 ± 2 cm H2O, p = 0.001), leading to higher plateau pressure, driving pressure, and mechanical power. The three PEEP strategies were not significantly different in gas exchange. The subgroup analysis showed that three PEEP strategies generated different effects in subjects with moderate or severe ARDS (n = 12) but not in subjects with mild ARDS (n = 8).Conclusions: In our cohort with COVID-19–induced ARDS, the ARDSnet low PEEP/FIO2 table and the best-oxygenation strategies led to higher PEEP and potentially higher risk of ventilator-induced lung injury than the best-compliance strategy.Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT04359251.

Increased duration and similar outcomes of V‐V ECLS in patients with COVID‐19 ARDS compared to non‐COVID ARDS: Single center experience

“…17,18 PEEP level was selected, by an incremental PEEP trial strategy (PEEP steps of 2 cmH 2 O up to 15 cmH 2 O), as described elsewhere. 19 The ECLS machine available at our institution is the Getinge Cardiohelp (Getinge AB, Göteborg, Sweden). The initial target of ECLS flow is usually tailored on the single patient, in order to obtain a PaO 2 > 60 mm Hg and PaCO 2 < 50 mm Hg.…”

“…Coronavirus Disease 2019 (COVID- 19), caused by the Severe Acute Respiratory Syndrome CoronaVirus-2 (SARS-CoV-2), can lead to development of acute respiratory distress syndrome (ARDS), needing intensive care unit (ICU) admission and invasive mechanical ventilation. 1,2 Since the beginning of the pandemic, high mortality rate in COVID-19 ARDS has been reported, despite application of protective mechanical ventilation.…”

Respiratory system mechanics, gas exchange, and outcomes in mechanically ventilated patients with COVID-19-related acute respiratory distress syndrome: a systematic review and meta-analysis

“…The pooled reported C RS in patients from studies of unselected COVID-19-related ARDS was 35·8 mL/cm H 2 O (95% CI 33·9–37·8; I 2 =96·9%, τ 2 =32·6; high certainty; figure 2 ). 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 In these studies, C RS dispersion was not significantly different from a normal distribution (Shapiro-Wilk test p=0·92; figure 3 ). The pooled reported C RS in all patients from studies of selected and unselected COVID-19-related ARDS was 34·7 mL/cm H 2 O (32·8–36·6; 97·2%, 43·6; high certainty; appendix p 5 ).…”

Clinical update on COVID-19 for the emergency clinician: Airway and resuscitation

“…A small study of 20 patients found after a recruitability assessment with a PEEP of 15 cm H 2 O, PaO 2 slightly improved (68.0 ± 10.3 vs. 69.7 ± 7.9 mmHg, p = 0.31) but PaCO 2 (72.5 ± 7.1 vs. 75.1 ± 9.0 mmHg; p < 0.01) and static respiratory system compliance (17.5 ± 3.5 vs. 16.6 ± 3.9 ml/cm H 2 O; p = 0.05) worsened [ 118 ]. Other studies of PEEP recruitment maneuvers found ventilation strategies utilizing ARDSnet low PEEP-FIO 2 table (PEEP 11 ± 6 cm H 2 O) and best‑oxygenation (highest PaO 2 /FiO 2 ) (PEEP 11 ± 3 cm H 2 O) led to higher PEEP, compared to the best-compliance strategy (6 ± 2 cm H 2 O, p = 0.001) [ 119 ]. This elevation in PEEP with use of the ARDSnet low PEEP-FiO2 table and best‑oxygenation strategy led to higher plateau and driving pressures and mechanical power, potentially increasing the risk of ventilator-induced lung injury, compared to the best-compliance strategy.…”

“…This elevation in PEEP with use of the ARDSnet low PEEP-FiO2 table and best‑oxygenation strategy led to higher plateau and driving pressures and mechanical power, potentially increasing the risk of ventilator-induced lung injury, compared to the best-compliance strategy. However, gas exchange was not significantly affected regardless of PEEP strategy [ 119 ].…”