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. 2022 Jun 27;11(13):3707.
doi: 10.3390/jcm11133707.

Methods for Determination of Individual PEEP for Intraoperative Mechanical Ventilation Using a Decremental PEEP Trial

Felix Girrbach  1 , Franziska Zeutzschel  1   2 , Susann Schulz  1 , Mirko Lange  1 , Alessandro Beda  3 , Antonio Giannella-Neto  4 , Hermann Wrigge  5   6 , Philipp Simon  7
Affiliations

Methods for Determination of Individual PEEP for Intraoperative Mechanical Ventilation Using a Decremental PEEP Trial

Felix Girrbach et al. J Clin Med. .

Abstract

(1) Background: Individual PEEP settings (PEEPIND) may improve intraoperative oxygenation and optimize lung mechanics. However, there is uncertainty concerning the optimal procedure to determine PEEPIND. In this secondary analysis of a randomized controlled clinical trial, we compared different methods for PEEPIND determination. (2) Methods: Offline analysis of decremental PEEP trials was performed and PEEPIND was retrospectively determined according to five different methods (EIT-based: RVDI method, Global Inhomogeneity Index [GI], distribution of tidal ventilation [EIT VT]; global dynamic and quasi-static compliance). (3) Results: In the 45 obese and non-obese patients included, PEEPIND using the RVDI method (PEEPRVD) was 16.3 ± 4.5 cm H2O. Determination of PEEPIND using the GI and EIT VT resulted in a mean difference of −2.4 cm H2O (95%CI: −1.2;−3.6 cm H2O, p = 0.01) and −2.3 cm H2O (95% CI: −0.9;3.7 cm H2O, p = 0.01) to PEEPRVD, respectively. PEEPIND selection according to quasi-static compliance showed the highest agreement with PEEPRVD (p = 0.67), with deviations > 4 cm H2O in 3/42 patients. PEEPRVD and PEEPIND according to dynamic compliance also showed a high level of agreement, with deviations > 4 cm H2O in 5/42 patients (p = 0.57). (4) Conclusions: High agreement of PEEPIND determined by the RVDI method and compliance-based methods suggests that, for routine clinical practice, PEEP selection based on best quasi-static or dynamic compliance is favorable.

Keywords: electrical impedance tomography; general anesthesia; mechanical ventilation; positive end-expiratory pressure.

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Conflict of interest statement

A.B. is an employee of Hamilton Medical. The other authors have no possible conflicts of interest to declare.

Figures

Figure 1
Figure 1
Example of a decremental PEEP trial and identification of PEEPIND using the RVDI method, illustrating the PEEP steps 20–6 cm H2O. Distribution of tidal ventilation significantly shifts to nondependent (ventral) lung areas with decreasing PEEP levels (top row). RVDI reaches its minimum at a PEEP level of 14 cm H2O (third row of images from top, line graph at the bottom). Likewise, Global Inhomogeneity Index (second row of images from top significantly increases below PEEP levels of 14 cm H2O. Maximum dynamic compliance was reached at a PEEP level of 16 cm H2O and was 152 mL/cm H2O.
Figure 2
Figure 2
PEEPIND values according to different methods for identification of PEEPIND. Median PEEP values did not differ between the RVDI method and quasi-static compliance measured during the inspiratory limb of the LFM. However, median PEEPIND values according to the minimal Global Inhomogeneity Index (GI) were around 2 cm H2O higher than according to the other methods.
Figure 3
Figure 3
Bland–Altman plot between PEEPIND using regional ventilation delay index (RVDI) and PEEPIND determination using quasi-static compliance as calculated by the least squares method (CQstat). Bias was 0.5 ± 3.18 cm H2O and did not differ between obese and non-obese patients (0.7 ± 2.7 cm H2O vs. 0.2 ± 3.7 cm H2O, p = 0.99). Additional Bland-Altman plots comparing RVDI, GI and compliance-based methods can be found in the Supplemental Material.
Figure 4
Figure 4
Correlation between dynamic compliance and quasi-static compliance of the respiratory system during the inspiratory limb of the low-flow maneuver (LFM)-based on the data calculated using the least squares method. Dynamic compliance and quasi-static compliance during the LFM highly correlated in both obese and non-obese patients.
Figure 5
Figure 5
Course of mean Regional Ventilatory Delay Index (A), mean Global Inhomogeneity Index and mean distribution of tidal ventilation to dependent (dorsal) lung areas in obese (red) and non-obese patients (green) during the decremental PEEP trial. While RVD shows considerable interindividual variation at each PEEP step (A), GI (B) is minimal at a PEEP of 18 cm H2O in normal weighted patients and at 20 cm H2O in obese patients. Likewise, best PEEP values according to the TV distribution method show best PEEP values at 20 cm H2O for obese patients and 16 cm H2O for non-obese patients (C).
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