Short-term effects of positive end-expiratory pressure titration strategies on lung clinical markers in COVID-19: A randomized controlled trial
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Published on: May 4, 2021
Wagner Souza Leite1, Shirley Lima Campos2, Caio César Araújo Morais3
1Graduate Program in Applied Health Biology, Federal University of Pernambuco, Recife, Pernambuco, Brazil.
Background:
Severe acute respiratory failure from COVID-19 is associated with high mortality. Optimal positive end-expiratory pressure (PEEP) titration is essential for lung-protective ventilation; however, different strategies may elicit distinct clinical responses.
Objective:
To compare the short-term effects of three PEEP titration strategies on lung injury score (LIS), changes in oxygenation, respiratory mechanics, and electrical impedance tomography (EIT) measures in mechanically ventilated patients with COVID-19.
Methods:
In this randomized, parallel-group trial, 75 intubated patients were randomly assigned to EIT-guided PEEP (PEEP-EIT), driving pressure-guided PEEP (PEEP-DP), or ARDSNet-based PEEP (PEEP-ARDSNet). Primary outcome was change in lung injury score (LIS); secondary outcomes included PaO₂/FiO₂ ≥ 150 mmHg, PaO₂/FiO₂ response ≥ 20 mmHg, driving pressure reduction, compliance increase, EIT-based regional ventilation and aeration, and adverse events within a four-hour follow-up.
Results:
Mean PEEP levels differed across groups: PEEP-EIT (13.3 cmH₂O), PEEP-DP (10.6 cmH₂O), and ARDSNet (12 cmH₂O). PEEP-EIT showed greater LIS reduction (ORweighted 3.7, 1.58 - 8.57; p = 0.004) and higher odds of oxygenation response vs. PEEP-DP (ORweighted 4.2, 2.15 - 8.27; p < 0.01) and PEEP-ARDSNet (ORweighted 3.6, 1.8- 7.1; p < 0.001). Both PEEP-EIT and PEEP-DP significantly improved driving pressure (PEEP-EIT: ORweighted 6.6, 2.6- 17.07; PEEP-DP: ORweighted 7.02, 2.7 - 18.2) and compliance (PEEP-EIT: ORweighted 9.5, 3.7- 24.33; PEEP-DP: ORweighted 5.94, 2.28 - 15.5) compared to PEEP-ARDSNet (p < 0.001 for both comparisons). No adverse events related to PEEP titration were reported.
Conclusion:
EIT-guided PEEP titration outperformed ARDSNet and DP-guided strategies in reducing lung injury and improving compliance and oxygenation in patients with COVID-19.
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