[en] BACKGROUND:
Selecting positive end-expiratory pressure (PEEP) during mechanical ventilation is important, as it can influence disease progression and outcome of acute respiratory distress syndrome (ARDS) patients. However, there are no well-established methods for optimizing PEEP selection due to the heterogeneity of ARDS. This research investigates the viability of titrating PEEP to minimum elastance for mechanically ventilated ARDS patients.
METHODS:
Ten mechanically ventilated ARDS patients from the Christchurch Hospital Intensive Care Unit were included in this study. Each patient underwent a stepwise PEEP recruitment manoeuvre. Airway pressure and flow data were recorded using a pneumotachometer. Patient-specific respiratory elastance (Ers ) and dynamic functional residual capacity (dFRC) at each PEEP level were calculated and compared. Optimal PEEP for each patient was identified by finding the minima of the PEEP-Ers profile.
RESULTS:
Median Ers and dFRC over all patients and PEEP values were 32.2 cmH2O/l [interquartile range (IQR) 25.0-45.9] and 0.42 l [IQR 0.11-0.87]. These wide ranges reflect patient heterogeneity and variable response to PEEP. The level of PEEP associated with minimum Ers corresponds to a high change of functional residual capacity, representing the balance between recruitment and minimizing the risk of overdistension.
CONCLUSIONS:
Monitoring patient-specific Ers can provide clinical insight to patient-specific condition and response to PEEP settings. The level of PEEP associated with minimum-Ers can be identified for each patient using a stepwise PEEP recruitment manoeuvre. This 'minimum elastance PEEP' may represent a patient-specific optimal setting during mechanical ventilation.
Disciplines :
General & internal medicine
Author, co-author :
Chiew, Yeong Shiong ; Université de Liège - ULiège > Département d'astrophys., géophysique et océanographie (AGO) > Thermodynamique des phénomènes irréversibles
Pretty, Christopher ; Université de Liège - ULiège > Département d'astrophys., géophysique et océanographie (AGO) > Thermodynamique des phénomènes irréversibles
SHAW, GM
CHIEW, YW
LAMBERMONT, Bernard ; Centre Hospitalier Universitaire de Liège - CHU > Frais communs médecine - Pool assistants
Desaive, Thomas ; Université de Liège - ULiège > Département d'astrophys., géophysique et océanographie (AGO) > Thermodynamique des phénomènes irréversibles
Chase, J Geoffrey ; Université de Liège - ULiège > Département d'astrophys., géophysique et océanographie (AGO) > Thermodynamique des phénomènes irréversibles
Language :
English
Title :
Feasibility of titrating PEEP to minimum elastance for mechanically ventilated patients.
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Esteban A, Anzueto A, Frutos F, Alia I, Brochard L, Stewart T, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA. 2002;287(3):345-55.
Gajic O, Dara SI, Mendez JL, Adesanya AO, Festic E, Caples SM, et al. Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation*. Crit Care Med. 2004;32(9):1817-24.
Gullo A, Berlot G, Garcia CSNB, Rocco PRM, Zin WA. Understanding the mechanism of ventilator-induced lung injury. Perioperative and critical care medicine. Milan: Springer; 2006. p. 43-59.
Girard TD, Bernard GR. Mechanical ventilation in ARDS. Chest. 2007;131(3):921-9.
Marini JJ, Gattinoni L. Ventilatory management of acute respiratory distress syndrome: a consensus of two. Crit Care Med. 2004;32:250-5.
Esteban A, Cook DJ, Anzueto A, Gattinoni L, Chiumello D, Vagginelli F. Management of patients with respiratory failure: an evidence-based approach. In: Vincent J-L, editor. Evidence-based management of patients with respiratory failure. Update in intensive care medicine. Berlin Heidelberg: Springer; 2005. p. 21-7.
Ashbaugh D, Boyd Bigelow D, Petty T, Levine B. Acute respiratory distress in adults. Lancet. 1967;290(7511):319-23.
Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, et al. The American-European consensus conference on ARDS: definitions, mechanisms, relevant outcomes and clinical trial coordination. Am J Respir Crit Care Med. 1994;149:818-24.
Brandstetter RD, Sharma KC, DellaBadia M, Cabreros LJ, Kabinoff GS. Adult respiratory distress syndrome: a disorder in need of improved outcome. Heart Lung: J Acute Crit Care. 1997;26(1):3-14. http://dx.doi.org/10.1016/S0147-9563(97)90004-2.
Desai A, Deep A. Ventilatory strategies and adjunctive therapy in ARDS. Indian J Pediatr. 2006;73(8):661-8. doi:10.1007/bf02898440.
Gattinoni L, Carlesso E, Brazzi L, Caironi P. Positive end-expiratory pressure. Curr Opin Crit Care. 2010;16(1):39-44.
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-8.
Brower RG, Lanken PN, MacIntyre N, Matthay MA, Morris A, Ancukiewicz M, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med. 2004;351(4):327-36.
Mercat A, Richard J-CM, Vielle B, Jaber S, Osman D, Diehl J-L, et al. Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2008;299(6):646-55. doi:10.1001/jama.299.6.646.
Meade MO, Cook DJ, Guyatt GH, Slutsky AS, Arabi YM, Cooper DJ, et al. Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2008;299(6):637-45. doi:10.1001/jama.299.6.637.
Briel M, Meade M, Mercat A, Brower RG, Talmor D, Walter SD, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA. 2010;303(9):865-73.
Ware LB, Matthay MA. The acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1334-49.
Stenqvist O. Practical assessment of respiratory mechanics. Br J Anaesth. 2003;91(1):92-105. doi:10.1093/bja/aeg141.
Sundaresan A, Chase JG. Positive end expiratory pressure in patients with acute respiratory distress syndrome - the past, present and future. Biomed Signal Process Control. 2011;7(2):93-103. doi:10.1016/j.bspc.2011.03.001.
Spieth P, Gama de Abreu M. Lung recruitment in ARDS: we are still confused, but on a higher PEEP level. Crit Care. 2012;16(1):108.
Kallet RH, Branson RD. Do the NIH ARDS Clinical Trials Network PEEP/FIO2 tables provide the best evidence-based guide to balancing PEEP and FIO2 settings in adults? Respir Care. 2007;52(4):461-77.
Suter P, Fairley B, Isenberg M. Optimum end-expiratory airway pressure in patients with acute pulmonary failure. N Engl J Med. 1975;292(6):284-9.
Suter PM, Fairley HB, Isenberg MD. Effect of tidal volume and positive end-expiratory pressure on compliance during mechanical ventilation. Chest. 1978;73:158-62.
Carvalho A, Jandre F, Pino A, Bozza F, Salluh J, Rodrigues R, et al. Positive end-expiratory pressure at minimal respiratory elastance represents the best compromise between mechanical stress and lung aeration in oleic acid induced lung injury. Crit Care. 2007;11(4):R86.
Suarez-Sipmann F, Bohm SH, Tusman G, Pesch T, Thamm O, Reissmann H, et al. Use of dynamic compliance for open lung positive end-expiratory pressure titration in an experimental study. Crit Care Med. 2007;35:214-21.
Lambermont B, Ghuysen A, Janssen N, Morimont P, Hartstein G, Gerard P, et al. Comparison of functional residual capacity and static compliance of the respiratory system during a positive end-expiratory pressure (PEEP) ramp procedure in an experimental model of acute respiratory distress syndrome. Crit Care. 2008;12(4):R91.
Pintado M-C, de Pablo R, Trascasa M, Milicua J-M, Rogero S, Daguerre M, et al. Individualized PEEP setting in subjects with ARDS: a randomized controlled pilot study. Respir Care. 2013;58(9):1416-23. doi:10.4187/respcare.02068.
Artigas A, Bernard Gordon R, Carlet J, Dreyfuss D, Gattinoni L, Hudson L, et al. The American-European Consensus Conference on ARDS, Part 2. Ventilatory, pharmacologic, supportive therapy, study design strategies, and issues related to recovery and remodeling. Am J Respir Crit Care Med. 1998;157(4):1332-47.
Gattinoni L, Caironi P, Cressoni M, Chiumello D, Ranieri VM, Quintel M, et al. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med. 2006;354(17):1775-86.
van Drunen E, Chiew YS, Chase J, Shaw G, Lambermont B, Janssen N, et al. Expiratory model-based method to monitor ARDS disease state. Bio Med Eng OnLine. 2013;12(1):57.
Lucangelo U, Bernabè F, Blanch L. Lung mechanics at the bedside: make it simple. Curr Opin Crit Care. 2007;13(1):64-72. doi:10.1097/MCC.0b013e32801162df.
Peslin R, da Silva JF, Chabot F, Duvivier C. Respiratory mechanics studied by multiple linear regression in unsedated ventilated patients. Eur Respir J. 1992;5(7):871-8.
Sundaresan A, Geoffrey Chase J, Hann CE, Shaw GM. Dynamic functional residual capacity can be estimated using a stress-strain approach. Comput Methods Programs Biomed. 2011;101(2):135-43.
Otis AB, Fenn WO, Rahn H. Mechanics of breathing in man. J Appl Physiol. 1950;2(11):592-607.
Marini JJ, Capps JS, Culver BH. The inspiratory work of breathing during assisted mechanical ventilation. Chest. 1985;87(5):612-8. doi:10.1378/chest.87.5.612.
Grinnan D, Truwit J. Clinical review: respiratory mechanics in spontaneous and assisted ventilation. Crit Care. 2005;9(5):472-84.
Kallet RH, Hemphill JC, Dicker RA, Alonso JA, Campbell AR, Mackersie RC, et al. The spontaneous breathing pattern and work of breathing of patients with acute respiratory distress syndrome and acute lung injury. Respir Care. 2007;52(8):989-95.
Mason RJ, Courtney Broaddus V, Martin TR, King TE, Schraufnagel DE, Murray JF, et al. Murray and Nadel's textbook of respiratory medicine. 5th ed. 2010.
Vieira Silvia RR, Puybasset L, Richecoeur J, Lu QIN, Cluzel P, Gusman Pablo B, et al. A Lung computed tomographic assessment of positive end-expiratory pressure-induced lung overdistension. Am J Respir Crit Care Med. 1998;158(5):1571-7.
Tusman G, Böhm SH, Vazquez de Anda GF, do Campo JL, Lachmann B. 'Alveolar recruitment strategy' improves arterial oxygenation during general anaesthesia. Br J Anaesth. 1999;82(1):8-13. doi:10.1093/bja/82.1.8.
Oczenski W, Hörmann C, Keller C, Lorenzl N, Kepka A, Schwarz S, et al. Recruitment maneuvers after a positive end-expiratory pressure trial do not induce sustained effects in early adult respiratory distress syndrome. Anesthesiology. 2004;101(3):620-5.
Meade MO, Cook DJ, Griffith LE, Hand LE, Lapinsky SE, Stewart TE, et al. A study of the physiologic responses to a lung recruitment maneuver in acute lung injury and acute respiratory distress syndrome. Respir Care. 2008;53(11):1441-9.
Guerin C, Debord S, Leray V, Delannoy B, Bayle F, Bourdin G, et al. Efficacy and safety of recruitment maneuvers in acute respiratory distress syndrome. Ann Intensive Care. 2011;1(1):9.
Suarez-Sipmann F, Bohm S. Recruit the lung before titrating the right positive end-expiratory pressure to protect it. Crit Care. 2009;13(3):134.
Khirani S, Polese G, Aliverti A, Appendini L, Nucci G, Pedotti A, et al. On-line monitoring of lung mechanics during spontaneous breathing: a physiological study. Respir Med. 2010;104(3):463-71.
van Drunen E, Chiew YS, Pretty C, Shaw G, Lambermont B, Janssen N, et al. Visualisation of time-varying respiratory system elastance in experimental ARDS animal models. BMC Pulm Med. 2014;14(1):33.
Fan E, Wilcox ME, Brower RG, Stewart TE, Mehta S, Lapinsky SE, et al. Recruitment maneuvers for acute lung injury. Am J Respir Crit Care Med. 2008;178(11):1156-63. doi:10.1164/rccm.200802-335OC.
Pelosi P, Gama de Abreu M, Rocco PR. New and conventional strategies for lung recruitment in acute respiratory distress syndrome. Crit Care. 2010;14:210.
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