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A novel positive end-expiratory pressure titration using electrical impedance tomography in spontaneously breathing acute respiratory distress syndrome patients on mechanical ventilation: an observational study from the MaastrICCht cohort

Affiliations
  • 1Department of Intensive Care, Maastricht University Medical Center+, P. Debyelaan 25, P.O. Box 5800, Maastricht, 6202, AZ, The Netherlands. S.heines@mumc.nl.
  • 2Department of Intensive Care, Maastricht University Medical Center+, P. Debyelaan 25, P.O. Box 5800, Maastricht, 6202, AZ, The Netherlands.
  • 3Department of Pulmonology, Medisch Spectrum Twente, Enschede, The Netherlands.
  • 4Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, P.O. Box 616, Maastricht, 6200 MD, The Netherlands.
  • 5Care and Public Health Research Institute (CAPHRI), Maastricht University, P.O. Box 616, Maastricht, 6200 MD, The Netherlands.
  • 6School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, P.O. Box 616, Maastricht, 6200 MD, The Netherlands.

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August 28, 2024

Abstract

There is no universally accepted method for positive end expiratory pressure (PEEP) titration approach for patients on spontaneous mechanical ventilation (SMV). Electrical impedance tomography (EIT) guided PEEP-titration has shown promising results in controlled mechanical ventilation (CMV), current implemented algorithm for PEEP titration (based on regional compliance measurements) is not applicable in SMV. Regional peak flow (RPF, defined as the highest inspiratory flow rate based on EIT at a certain PEEP level) is a new method for quantifying regional lung mechanics designed for SMV. The objective is to study whether RPF by EIT is a feasible method for PEEP titration during SMV. Single EIT measurements were performed in COVID-19 ARDS patients on SMV. Clinical (i.e., tidal volume, airway occlusion pressure, end-tidal CO) and mechanical (cyclic alveolar recruitment, recruitment, cumulative overdistension (OD), cumulative collapse (CL), pendelluft, and PEEP) outcomes were determined by EIT at several pre-defined PEEP thresholds (1-10% CL and the intersection of the OD and CL curves) and outcomes at all thresholds were compared to the outcomes at baseline PEEP. In total, 25 patients were included. No significant and clinically relevant differences were found between thresholds for tidal volume, end-tidal CO, and P0.1 compared to baseline PEEP; cyclic alveolar recruitment rates changed by -3.9% to -37.9% across thresholds; recruitment rates ranged from - 49.4% to + 79.2%; cumulative overdistension changed from - 75.9% to + 373.4% across thresholds; cumulative collapse changed from 0% to -94.3%; PEEP levels from 10 up to 14 cmHO were observed across thresholds compared to baseline PEEP of 10 cmHO. A threshold of approximately 5% cumulative collapse yields the optimum compromise between all clinical and mechanical outcomes. EIT-guided PEEP titration by the RPF approach is feasible and is linked to improved overall lung mechanics) during SMV using a threshold of approximately 5% CL. However, the long-term clinical safety and effect of this approach remain to be determined.

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