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. 2022 Mar 26;26(1):82.
doi: 10.1186/s13054-022-03956-8.

Effects of different positive end-expiratory pressure titration strategies during prone positioning in patients with acute respiratory distress syndrome: a prospective interventional study

Christoph Boesing  1 , Peter T Graf  1 , Fabian Schmitt  1 , Manfred Thiel  1 , Paolo Pelosi  2   3 , Patricia R M Rocco  4 , Thomas Luecke  1 , Joerg Krebs  5
Affiliations

Effects of different positive end-expiratory pressure titration strategies during prone positioning in patients with acute respiratory distress syndrome: a prospective interventional study

Christoph Boesing et al. Crit Care. .

Abstract

Background: Prone positioning in combination with the application of low tidal volume and adequate positive end-expiratory pressure (PEEP) improves survival in patients with moderate to severe acute respiratory distress syndrome (ARDS). However, the effects of PEEP on end-expiratory transpulmonary pressure (Ptpexp) during prone positioning require clarification. For this purpose, the effects of three different PEEP titration strategies on Ptpexp, respiratory mechanics, mechanical power, gas exchange, and hemodynamics were evaluated comparing supine and prone positioning.

Methods: In forty consecutive patients with moderate to severe ARDS protective ventilation with PEEP titrated according to three different titration strategies was evaluated during supine and prone positioning: (A) ARDS Network recommendations (PEEPARDSNetwork), (B) the lowest static elastance of the respiratory system (PEEPEstat,RS), and (C) targeting a positive Ptpexp (PEEPPtpexp). The primary endpoint was to analyze whether Ptpexp differed significantly according to PEEP titration strategy during supine and prone positioning.

Results: Ptpexp increased progressively with prone positioning compared with supine positioning as well as with PEEPEstat,RS and PEEPPtpexp compared with PEEPARDSNetwork (positioning effect p < 0.001, PEEP strategy effect p < 0.001). PEEP was lower during prone positioning with PEEPEstat,RS and PEEPPtpexp (positioning effect p < 0.001, PEEP strategy effect p < 0.001). During supine positioning, mechanical power increased progressively with PEEPEstat,RS and PEEPPtpexp compared with PEEPARDSNetwork, and prone positioning attenuated this effect (positioning effect p < 0.001, PEEP strategy effect p < 0.001). Prone compared with supine positioning significantly improved oxygenation (positioning effect p < 0.001, PEEP strategy effect p < 0.001) while hemodynamics remained stable in both positions.

Conclusions: Prone positioning increased transpulmonary pressures while improving oxygenation and hemodynamics in patients with moderate to severe ARDS when PEEP was titrated according to the ARDS Network lower PEEP table. This PEEP titration strategy minimized parameters associated with ventilator-induced lung injury induction, such as transpulmonary driving pressure and mechanical power. We propose that a lower PEEP strategy (PEEPARDSNetwork) in combination with prone positioning may be part of a lung protective ventilation strategy in patients with moderate to severe ARDS.

Trial registration: German Clinical Trials Register ( DRKS00017449 ). Registered June 27, 2019. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017449.

Keywords: Acute respiratory distress syndrome; Lung protective ventilation; Positive end-expiratory pressure; Prone position; Respiratory mechanics; Transpulmonary pressure; Ventilator-induced lung injury.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Schematic workflow of the study. PEEP positive end-expiratory pressure, PEEPARDSNetwork PEEP titrated according to the ARDS Network lower PEEP table, PEEPEstat,RS PEEP titrated according to the lowest elastance of the respiratory system, PEEPPtpexp PEEP titrated according to end-expiratory transpulmonary pressure
Fig. 2
Fig. 2
Effects of different PEEP titration strategies on Ptpexp and Ptpinsp during supine and prone positioning. A Ptpexp evaluated according to different PEEP titration strategies during supine and prone positioning. B Ptpinsp evaluated according to different PEEP titration strategies during supine and prone positioning. Bars are means + SD of 40 patients with moderate to severe ARDS. Brackets denote statistically significant differences between PEEP titration strategies, p-values are shown above the brackets. PEEP positive end-expiratory pressure, PEEPARDSNetwork PEEP titrated according to the ARDS Network lower PEEP table, PEEPEstat,RS PEEP titrated according to the lowest elastance of the respiratory system, PEEPPtpexp PEEP titrated according to end-expiratory transpulmonary pressure, Ptpexp end-expiratory transpulmonary pressure, Ptpinsp end-inspiratory transpulmonary pressure
Fig. 3
Fig. 3
Effects of different PEEP titration strategies on PEEP and Pplat during supine and prone positioning. A PEEP setting according to different PEEP titration strategies during supine and prone positioning. B Pplat evaluated according to different PEEP titration strategies during supine and prone positioning. Bars are means + SD of 40 patients with moderate to severe ARDS. Brackets denote statistically significant differences between PEEP titration strategies strategies, p-values are shown above the brackets. PEEP positive end-expiratory pressure, PEEPARDSNetwork PEEP titrated according to the ARDS Network lower PEEP table, PEEPEstat,RS PEEP titrated according to the lowest elastance of the respiratory system, PEEPPtpexp PEEP titrated according to end-expiratory transpulmonary pressure, Pplat end-inspiratory plateau airway pressure
Fig. 4
Fig. 4
Effects of different PEEP titration strategies on Pdriv and Ptpdriv during supine and prone positioning. A Pdriv evaluated according to different PEEP titration strategies during supine and prone positioning. B Ptpdriv evaluated according to different PEEP titration strategies during supine and prone positioning. Bars are means + SD of 40 patients with moderate to severe ARDS. Brackets denote statistically significant differences between PEEP titration strategies strategies, p-values are shown above the brackets. Pdriv driving pressure, PEEP positive end-expiratory pressure, PEEPARDSNetwork PEEP titrated according to the ARDS Network lower PEEP table, PEEPEstat,RS PEEP titrated according to the lowest elastance of the respiratory system, PEEPPtpexp PEEP titrated according to end-expiratory transpulmonary pressure, Ptpdriv transpulmonary driving pressure pressure
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