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. 2022 Apr:298:103844.
doi: 10.1016/j.resp.2022.103844. Epub 2022 Jan 14.

Hemodynamic response to positive end-expiratory pressure and prone position in COVID-19 ARDS

Antonio Maria Dell'Anna  1 , Simone Carelli  1 , Marta Cicetti  1 , Claudia Stella  1 , Filippo Bongiovanni  1 , Daniele Natalini  1 , Eloisa Sofia Tanzarella  1 , Paolo De Santis  1 , Maria Grazia Bocci  1 , Gennaro De Pascale  2 , Domenico Luca Grieco  3 , Massimo Antonelli  2
Affiliations

Hemodynamic response to positive end-expiratory pressure and prone position in COVID-19 ARDS

Antonio Maria Dell'Anna et al. Respir Physiol Neurobiol. 2022 Apr.

Abstract

Background: Use of high positive end-expiratory pressure (PEEP) and prone positioning is common in patients with COVID-19-induced acute respiratory failure. Few data clarify the hemodynamic effects of these interventions in this specific condition. We performed a physiologic study to assess the hemodynamic effects of PEEP and prone position during COVID-19 respiratory failure.

Methods: Nine adult patients mechanically ventilated due to COVID-19 infection and fulfilling moderate-to-severe ARDS criteria were studied. Respiratory mechanics, gas exchange, cardiac output, oxygen consumption, systemic and pulmonary pressures were recorded through pulmonary arterial catheterization at PEEP of 15 and 5 cmH2O, and after prone positioning. Recruitability was assessed through the recruitment-to-inflation ratio.

Results: High PEEP improved PaO2/FiO2 ratio in all patients (p = 0.004), and significantly decreased pulmonary shunt fraction (p = 0.012), regardless of lung recruitability. PEEP-induced increases in PaO2/FiO2 changes were strictly correlated with shunt fraction reduction (rho=-0.82, p = 0.01). From low to high PEEP, cardiac output decreased by 18 % (p = 0.05) and central venous pressure increased by 17 % (p = 0.015). As compared to supine position with low PEEP, prone positioning significantly decreased pulmonary shunt fraction (p = 0.03), increased PaO2/FiO2 (p = 0.03) and mixed venous oxygen saturation (p = 0.016), without affecting cardiac output. PaO2/FiO2 was improved by prone position also when compared to high PEEP (p = 0.03).

Conclusions: In patients with moderate-to-severe ARDS due to COVID-19, PEEP and prone position improve arterial oxygenation. Changes in cardiac output contribute to the effects of PEEP but not of prone position, which appears the most effective intervention to improve oxygenation with no hemodynamic side effects.

Keywords: ARDS; COVID-19; Cardiac output; Hemodynamic monitoring; PEEP; Prone position; Pulmonary artery catheter; Pulmonary shunt; SARS-CoV-2.

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Conflict of interest statement

All authors declare that no conflict of interests exists regarding the material discussed in the manuscript.

Figures

Fig. 1
Fig. 1
PaO2/FiO2 and pulmonary shunt fraction in the three study phases. Individual data are displayed.
Fig. 2
Fig. 2
PEEP-induced changes in PaO2/FiO2 (ΔP/F) are tightly correlated by the reduction in pulmonary shunt fraction (ΔShunt) caused by PEEP.
See this image and copyright information in PMC

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