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. 2019 Jul 16;9(1):81.
doi: 10.1186/s13613-019-0554-3.

PEEP titration in moderate to severe ARDS: plateau versus transpulmonary pressure

Marie Bergez  1 , Nicolas Fritsch  1 , David Tran-Van  1 , Tahar Saghi  2 , Tan Bounkim  3 , Ariane Gentile  1 , Philippe Labadie  1 , Bruno Fontaine  1 , Alexandre Ouattara  4   5 , Hadrien Rozé  6
Affiliations

PEEP titration in moderate to severe ARDS: plateau versus transpulmonary pressure

Marie Bergez et al. Ann Intensive Care. .

Abstract

Background: Although lung protection with low tidal volume and limited plateau pressure (Pplat) improves survival in acute respiratory distress syndrome patients (ARDS), the best way to set positive end-expiratory pressure (PEEP) is still debated.

Methods: This study aimed to compare two strategies using individual PEEP based on a maximum Pplat (28-30 cmH2O, the Express group) or on keeping end-expiratory transpulmonary pressure positive (0-5 cmH2O, PLexpi group). We estimated alveolar recruitment (Vrec), end-expiratory lung volume and alveolar distension based on elastance-related end-inspiratory transpulmonary pressure (PL,EL).

Results: Nineteen patients with moderate to severe ARDS (PaO2/FiO2 < 150 mmHg) were included with a baseline PEEP of 7.0 ± 1.8 cmH2O and a PaO2/FiO2 of 91.2 ± 31.2 mmHg. PEEP and oxygenation increased significantly from baseline with both protocols; PEEP Express group was 14.2 ± 3.6 cmH2O versus 16.7 ± 5.9 cmH2O in PLexpi group. No patient had the same PEEP with the two protocols. Vrec was higher with the latter protocol (299 [0 to 875] vs. 222 [47 to 483] ml, p = 0.049) and correlated with improved oxygenation (R2 = 0.45, p = 0.002). Two and seven patients in the Express and PL,expi groups, respectively, had PL,EL > 25 cmH2O.

Conclusions: There is a great heterogeneity of PLexpi when Pplat is used to titrate PEEP but with limited risk of over-distension. A PEEP titration for a moderate positive level of PLexpi might slightly improve alveolar recruitment and oxygenation but increases the risk of over-distension in one-third of patients.

Keywords: ARDS; Monitoring; PEEP titration; Transpulmonary pressure.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Individual PEEP levels according to the Express or PLexpi protocol. PEEP increased from baseline but is individually different for almost all patients with each protocol Express or PLexpi
Fig. 2
Fig. 2
Individual PLexpi levels according to baseline, Express and PLexpi protocols. PLexpi = positive end-expiratory transpulmonary pressure. Dash line represents the limit of 0 cmH2O; more patients had negative PLexpi with the Express protocol
Fig. 3
Fig. 3
Individual PL,EL with baseline, Express and PLexpi protocols. PL,EL = elastance-derived calculation of relative end-inspiratory transpulmonary pressure. Dash line represents the limit of 25 cmH2O; more patients had PL,EL above 25 cmH2O with the PLexpi protocol
See this image and copyright information in PMC

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