OBJECTIVE:: Positive end-expiratory pressure exerts its effects keeping open at end-expiration previously collapsed areas of the lung; consequently, higher positive end-expiratory pressure should be limited to patients with high recruitability. We aimed to determine which bedside method would provide positive end-expiratory pressure better related to lung recruitability. DESIGN:: Prospective study performed between 2008 and 2011. SETTING:: Two university hospitals (Italy and Germany). PATIENTS:: Fifty-one patients with acute respiratory distress syndrome. INTERVENTIONS:: Whole lung CT scans were taken in static conditions at 5 and 45 cm H2O during an end-expiratory/end-inspiratory pause to measure lung recruitability. To select individual positive end-expiratory pressure, we applied bedside methods based on lung mechanics (ExPress, stress index), esophageal pressure, and oxygenation (higher positive end-expiratory pressure table of lung open ventilation study). MEASUREMENTS AND MAIN RESULTS:: Patients were classified in mild, moderate and severe acute respiratory distress syndrome. Positive end-expiratory pressure levels selected by the ExPress, stress index, and absolute esophageal pressures methods were unrelated with lung recruitability, whereas positive end-expiratory pressure levels selected by the lung open ventilation method showed a weak relationship with lung recruitability (r = 0.29; p < 0.0001). When patients were classified according to the acute respiratory distress syndrome Berlin definition, the lung open ventilation method was the only one which gave lower positive end-expiratory pressure levels in mild and moderate acute respiratory distress syndrome compared with severe acute respiratory distress syndrome (8 ± 2 and 11 ± 3 cm H2O vs 15 ± 3 cm H2O; p < 0.05), whereas ExPress, stress index, and esophageal pressure methods gave similar positive end-expiratory pressure values in mild, moderate, and severe acute respiratory distress syndrome. The positive end-expiratory pressure selected by the different methods were unrelated to each other with the exception of the two methods based on lung mechanics (ExPress and stress index). CONCLUSIONS:: Bedside positive end-expiratory pressure selection methods based on lung mechanics or absolute esophageal pressures provide positive end-expiratory pressure levels unrelated to lung recruitability and similar in mild, moderate, and severe acute respiratory distress syndrome, whereas the oxygenation-based method provided positive end-expiratory pressure levels related with lung recruitability progressively increasing from mild to moderate and severe acute respiratory distress syndrome.
Bedside selection of positive end-expiratory pressure in mild, moderate, and severe acute respiratory distress syndrome / D. Chiumello, M. Cressoni, E. Carlesso, M.L. Caspani, A. Marino, E. Gallazzi, P. Caironi, M. Lazzerini, O. Moerer, M. Quintel, L. Gattinoni. - In: CRITICAL CARE MEDICINE. - ISSN 0090-3493. - 42:2(2014 Feb), pp. 252-264.
|Titolo:||Bedside selection of positive end-expiratory pressure in mild, moderate, and severe acute respiratory distress syndrome|
GATTINONI, LUCIANO (Ultimo)
|Parole Chiave:||Acute Respiratory Distress Syndrome; Lung; Lung Collapse; Positive End-Expiratory Pressure; Positive-Pressure Respiration; Respiratory Mechanics|
|Settore Scientifico Disciplinare:||Settore MED/41 - Anestesiologia|
|Data di pubblicazione:||feb-2014|
|Digital Object Identifier (DOI):||http://dx.doi.org/10.1097/CCM.0b013e3182a6384f|
|Appare nelle tipologie:||01 - Articolo su periodico|