PEEP titration in ARDS: from oxygenation and compliance to EIT-guided regional respiratory physiology parameters

doi:10.3877/cma.j.issn.2096-1537.2024.02.002

Abstract

Abstract:

There has been debate on the optimal approach for determining the appropriate positive end-expiratory pressure (PEEP) setting in the treatment of acute respiratory distress syndrome (ARDS). Recently, more and more evidence suggests that the currently used oxygenation and maximum compliance methods for titrating optimal PEEP have certain limitations and cannot effectively reflect regional alveolar recruitment and overexpansion. This article mainly elaborates on the potential misunderstandings of oxygenation and compliance methods for titrating PEEP, and proposes a PEEP setting "CODP" whole strategy based on electrical impedance tomography local respiratory physiology parameters, serving as a guide for clinical practice.

Key words: Electrical impedance tomography, Positive end-expiratory pressure titration, Oxygenation, Compliance

Siyi Yuan, Huaiwu He, Yun Long. PEEP titration in ARDS: from oxygenation and compliance to EIT-guided regional respiratory physiology parameters[J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2024, 10(02): 102-107.

/ / Recommend

Add to citation manager EndNote|Ris|BibTeX

URL: https://icu.cma-cmc.com.cn/EN/10.3877/cma.j.issn.2096-1537.2024.02.002

https://icu.cma-cmc.com.cn/EN/Y2024/V10/I02/102

Figures/Tables 1

References 37

1	Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome [J]. N Engl J Med, 2004, 351(4): 327-336.
2	Mauri T, Spinelli E, Scotti E, et al. Potential for lung recruitment and ventilation-perfusion mismatch in patients with the acute respiratory distress syndrome from coronavirus disease 2019 [J]. Crit Care Med, 2020, 48(8): 1129-1134.
3	Gattinoni L, Chiumello D, Caironi P, et al. COVID-19 pneumonia: different respiratory treatments for different phenotypes? [J]. Intensive Care Med, 2020, 46(6): 1099-1102.
4	Gattinoni L, Pesenti A, Avalli L, et al. Pressure-volume curve of total respiratory system in acute respiratory failure. Computed tomographic scan study [J]. Am Rev Respir Dis, 1987, 136(3): 730-736.
5	Protti A, Santini A, Pennati F, et al. Lung response to a higher positive end-expiratory pressure in mechanically ventilated patients with COVID-19 [J]. Chest, 2022, 161(4): 979-988.
6	Grieco DL, Bongiovanni F, Chen L, et al. Respiratory physiology of COVID-19-induced respiratory failure compared to ARDS of other etiologies [J]. Crit Care, 2020, 24(1): 529.
7	Cavalcanti AB, Suzumura ÉA, Laranjeira LN, et al. Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) vs (Low) PEEP on mortality in patients with acute respiratory distress syndrome: a randomized clinical trial [J]. JAMA, 2017, 318(14): 1335-1345.
8	Fan E, Del Sorbo L, Goligher EC, et al. An Official American Thoracic Society/European Society of Intensive Care Medicine,/Society of Critical Care Medicine, Clinical Practice Guideline: mechanical ventilation in adult patients with acute respiratory distress syndrome [J]. Am J Respir Crit Care Med, 2017, 195(9): 1253-1263.
9	Dianti J, Tisminetzky M, Ferreyro BL, et al. Association of positive end-expiratory pressure and lung recruitment selection strategies with mortality in acute respiratory distress syndrome: a systematic review and network meta-analysis [J]. Am J Respir Crit Care Med, 2022, 205(11): 1300-1310.
10	Briel M, Meade M, Mercat A, 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 [J]. JAMA, 2010, 303(9): 865-873.
11	Grasselli G, Calfee CS, Camporota L, et al. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies [J]. Intensive Care Med, 2023, 49(7): 727-759.
12	Qadir N, Sahetya S, Munshi L, et al. An update on management of adult patients with acute respiratory distress syndrome: an official American Thoracic Society clinical practice guideline [J]. Am J Respir Crit Care Med, 2024, 209(1): 24-36.
13	Mercat A, Richard JC, Vielle B, et al. Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial [J]. JAMA, 2008, 299(6): 646-655.
14	Meade MO, Cook DJ, Guyatt GH, 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 [J]. JAMA, 2008, 299(6): 637-645.
15	Beitler JR, Sarge T, Banner-Goodspeed VM, et al. Effect of titrating positive end-expiratory pressure (peep) with an esophageal pressure-guided strategy vs an empirical high PEEP-FiO₂ strategy on death and days free from mechanical ventilation among patients with acute respiratory distress syndrome: a randomized clinical trial [J]. JAMA, 2019, 321(9): 846-857.
16	Gattinoni L, Tonetti T, Quintel M. Regional physiology of ARDS [J]. Crit Care, 2017, 21(Suppl 3): 312.
17	Gattinoni L, Caironi P, Cressoni M, et al. Lung recruitment in patients with the acute respiratory distress syndrome [J]. N Engl J Med, 2006, 354(17): 1775-1786.
18	Jimenez JV, Weirauch AJ, Culter CA, et al. Electrical impedance tomography in acute respiratory distress syndrome management [J]. Crit Care Med, 2022, 50(8): 1210-1223.
19	Costa EL, Borges JB, Melo A, et al. Bedside estimation of recruitable alveolar collapse and hyperdistension by electrical impedance tomography [J]. Intensive Care Med, 2009, 35(6): 1132-1137.
20	Zhao Z, Chang MY, Chang MY, et al. Positive end-expiratory pressure titration with electrical impedance tomography and pressure-volume curve in severe acute respiratory distress syndrome [J]. Ann Intensive Care, 2019, 9(1): 7.
21	Franchineau G, Bréchot N, Lebreton G, et al. Bedside contribution of electrical impedance tomography to setting positive end-expiratory pressure for extracorporeal membrane oxygenation-treated patients with severe acute respiratory distress syndrome [J]. Am J Respir Crit Care Med, 2017, 196(4): 447-457.
22	Karsten J, Grusnick C, Paarmann H, et al. Positive end-expiratory pressure titration at bedside using electrical impedance tomography in post-operative cardiac surgery patients [J]. Acta Anaesthesiol Scand, 2015, 59(6): 723-732.
23	Zhao Z, Steinmann D, Frerichs I, et al. PEEP titration guided by ventilation homogeneity: a feasibility study using electrical impedance tomography [J]. Crit Care, 2010, 14(1): R8.
24	Blankman P, Hasan D, Erik G, et al. Detection of 'best' positive end-expiratory pressure derived from electrical impedance tomography parameters during a decremental positive end-expiratory pressure trial [J]. Crit Care, 2014, 18(3): R95.
25	Erlandsson K, Odenstedt H, Lundin S, et al. Positive end-expiratory pressure optimization using electric impedance tomography in morbidly obese patients during laparoscopic gastric bypass surgery [J]. Acta Anaesthesiol Scand, 2006, 50(7): 833-839.
26	Wrigge H, Zinserling J, Muders T, et al. Electrical impedance tomography compared with thoracic computed tomography during a slow inflation maneuver in experimental models of lung injury [J]. Crit Care Med, 2008, 36(3): 903-909.
27	He H, Chi Y, Yang Y, et al. Early individualized positive end-expiratory pressure guided by electrical impedance tomography in acute respiratory distress syndrome: a randomized controlled clinical trial [J]. Crit Care, 2021, 25(1): 230.
28	Hsu HJ, Chang HT, Zhao Z, et al. Positive end-expiratory pressure titration with electrical impedance tomography and pressure-volume curve: a randomized trial in moderate to severe ARDS [J]. Physiol Meas, 2021, 42(1): 014002.
29	Jimenez JV, Munroe E, Weirauch AJ, et al. Electric impedance tomography-guided PEEP titration reduces mechanical power in ARDS: a randomized crossover pilot trial [J]. Crit Care, 2023, 27(1): 21.
30	Heines SJH, de Jongh SAM, Strauch U,et al. The global inhomogeneity index assessed by electrical impedance tomography overestimates PEEP requirement in patients with ARDS: an observational study [J]. BMC Anesthesiol, 2022, 22(1): 258.
31	Zhao Z, Lee LC, Chang MY, et al. The incidence and interpretation of large differences in EIT-based measures for PEEP titration in ARDS patients [J]. J Clin Monit Comput, 2020, 34(5): 1005-1013.
32	Brito R, Morais CCA, Lazo MT, et al. Dynamic relative regional lung strain estimated by computed tomography and electrical impedance tomography in ARDS patients [J]. Crit Care, 2023, 27(1): 457.
33	Dalla Corte F, Mauri T, Spinelli E, et al. Dynamic bedside assessment of the physiologic effects of prone position in acute respiratory distress syndrome patients by electrical impedance tomography [J]. Minerva Anestesiol, 2020, 86(10): 1057-1064.
34	Franchineau G, Bréchot N, Hekimian G, et al. Prone positioning monitored by electrical impedance tomography in patients with severe acute respiratory distress syndrome on veno-venous ECMO [J]. Ann Intensive Care, 2020, 10(1): 12.
35	Lima JNG, Fontes MS, Szmuszkowicz T, et al. Electrical impedance tomography monitoring during spontaneous breathing trial: Physiological description and potential clinical utility [J]. Acta Anaesthesiol Scand, 2019, 63(8): 1019-1027.
36	池熠, 何怀武, 隆云. 重症患者呼吸钟摆现象的研究进展 [J/OL]. 中华重症医学电子杂志, 2022, 8(1): 62-66.
37	Chi Y, Zhao Z, Frerichs I, et al. Prevalence and prognosis of respiratory pendelluft phenomenon in mechanically ventilated ICU patients with acute respiratory failure: a retrospective cohort study [J]. Ann Intensive Care, 2022, 12(1): 22.

[1]	Liang Liang, Zheng Tan, Ting Huang, Yue Gao, Jian Zhang, Jie Xia. Risk factors of postoperative respiratory support in newborns with congenital diaphragmatic hernia [J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2024, 20(01): 9-17.
[2]	Luhao Liu, Yongxin Su, Lijuan Zeng, Peng Zhang, Rongxin Chen, Lu Xu, Guanghui Li, Jiali Fang, Junjie Ma, Zheng Chen. Drug compliance of immunosuppressant in kidney transplant recipients during the COVID-19 pandemic [J]. Chinese Journal of Transplantation(Electronic Edition), 2023, 17(03): 140-145.
[3]	Mingzhu Huang, Ying Lu, Kang He, Yan Wang. Investigation and analysis of medication compliance of pediatric liver transplant recipients after discharge [J]. Chinese Journal of Transplantation(Electronic Edition), 2023, 17(02): 112-117.
[4]	Xiaofang Cai, Hui Gao, Jun Ge, Huiyun Xing, Xiaoyan Zhuang, Xiaoding Li. Prediction and analysis of treatment compliance of multi-drug resistant pulmonary tuberculosis [J]. Chinese Journal of Lung Diseases(Electronic Edition), 2024, 17(01): 51-56.
[5]	Liling Xu, Yubao Lu, Yan Zhao, Li Ren, Shuyi Li, Juan Fu, Ling Kang, Qingsong Wang, Zaichun You. Construction and clinical application of chronic obstructive pulmonary disease management cloud platform [J]. Chinese Journal of Lung Diseases(Electronic Edition), 2023, 16(04): 481-484.
[6]	Wenzhe Li, Pengfei Pan, Jian Cui, Xiangyou Yu. Ethical issues in the clinical application of extracorporeal life support [J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2024, 10(02): 97-101.
[7]	Jingjing Wang, Hui Xie, Puyu Deng, Chenchen Zhang, Xue Tian, Yun Xie, Ruilan Wang. Prone positioning improves ventilation distribution and ventilation-perfusion matching assessed by electrical impedance tomography in COVID-19 patients with ARDS [J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2024, 10(01): 31-37.
[8]	Mengru Xu, Huaiwu He, Yi Chi, Xiaotong Sun, Yun Long, Zhanqi Zhao. Study of reference range for lung ventilation parameters measured by electrical impedance tomography in Chinese health adults [J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2023, 09(04): 360-367.
[9]	Ke Fang, Huanhuan Da, Jun Wang, Ruixiang Sun, Tao Wang, Yang Li, Haijiao Jiang, Weihua Lu. ECMO assisted adrenal excision for pheochromocytoma catecholamine cardiomyopathy during pregnancy: a case report and literature review [J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2023, 09(03): 304-310.
[10]	Xuehui Gao, Xiaojing Zou, Xiaobo Yang, You Shang. Anticoagulation application of Nafamostat Mesylate in critically ill patients received continuous renal replacement therapy and extracorporeal membrane oxygenation [J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2023, 09(02): 210-216.
[11]	Ruixue Sun, Li Zhu, Wenli Liu. Analysis of medication compliance, medication attitude and influencing factors in children with diarrhea [J]. Chinese Journal of Digestion and Medical Imageology(Electronic Edition), 2024, 14(01): 72-76.
[12]	Liang Liu, Hao Xiao, Xiaolei Cui, Baopu Lv, Rui Zhang, Tuokang Zheng, Qingbing Meng, Dongqi Yao, Yingping Tian, Hengbo Gao. Prognostic factors in patients with acute myocardial infarction combined with cardiogenic shock: analysis of 97 cases [J]. Chinese Journal of Clinicians(Electronic Edition), 2024, 18(02): 183-189.
[13]	Wei Liu, Min Zhang, Mei Ling Jie, Qunqun Yu, Na Zhou, Guangping Chen, Xiang Yang, Yali Chen, Meihua Liu. Effect of hospital-community integration pattern on management of hypertension [J]. Chinese Journal of Clinicians(Electronic Edition), 2023, 17(11): 1176-1180.
[14]	Lei Xiang, Qi Yang, Hui Xie, Haitao Liu, Feng Xia, Weishun Lan, Wenzhong Yang. Application of non-compliant balloon occlusion of abdominal aorta during cesarean section of pernicious placenta previa with placental implantation [J]. Chinese Journal of Interventional Radiology(Electronic Edition), 2023, 11(02): 106-112.
[15]	Li Xue, Xiaozhong Gao. Establishment of prediction model for medication compliance of helicobacter pylori- positive patients [J]. Chinese Journal of Gastrointestinal Endoscopy(Electronic Edition), 2024, 11(01): 23-27.

Please choose a citation manager

Content to export