Jacopo Fumagalli1, Roberta R S Santiago, Maddalena Teggia Droghi, Changsheng Zhang, Florian J Fintelmann, Fabian M Troschel, Caio C A Morais, Marcelo B P Amato, Robert M Kacmarek, Lorenzo Berra. 1. From the Department of Anesthesia, Critical Care and Pain Medicine (J.F., R.R.S.S., M.T.D., C.Z., L.B.) the Respiratory Care Department (R.M.K.) the Department of Radiology (F.J.F., F,M.T.), Massachusetts General Hospital, Boston, Massachusetts the Pulmonary Division, Cardio-Pulmonary Department, Heart Institute (Incor), Hospital Das Clínicas, Faculty of Medicine, University of Sao Paulo, São Paulo, Brazil (C.C.A.M., M.B.P.A.). Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts Respiratory Care Department, Massachusetts General Hospital, Boston, Massachusetts Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts.
Abstract
BACKGROUND: Obese patients are characterized by normal chest-wall elastance and high pleural pressure and have been excluded from trials assessing best strategies to set positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS). The authors hypothesized that severely obese patients with ARDS present with a high degree of lung collapse, reversible by titrated PEEP preceded by a lung recruitment maneuver. METHODS: Severely obese ARDS patients were enrolled in a physiologic crossover study evaluating the effects of three PEEP titration strategies applied in the following order: (1) PEEPARDSNET: the low PEEP/FIO2 ARDSnet table; (2) PEEPINCREMENTAL: PEEP levels set to determine a positive end-expiratory transpulmonary pressure; and (3) PEEPDECREMENTAL: PEEP levels set to determine the lowest respiratory system elastance during a decremental PEEP trial following a recruitment maneuver on respiratory mechanics, regional lung collapse, and overdistension according to electrical impedance tomography and gas exchange. RESULTS: Fourteen patients underwent the study procedures. At PEEPARDSNET (13 ± 1 cm H2O) end-expiratory transpulmonary pressure was negative (-5 ± 5 cm H2O), lung elastance was 27 ± 12 cm H2O/L, and PaO2/FIO2 was 194 ± 111 mmHg. Compared to PEEPARDSNET, at PEEPINCREMENTAL level (22 ± 3 cm H2O) lung volume increased (977 ± 708 ml), lung elastance decreased (23 ± 7 cm H2O/l), lung collapse decreased (18 ± 10%), and ventilation homogeneity increased thus rising oxygenation (251 ± 105 mmHg), despite higher overdistension levels (16 ± 12%), all values P < 0.05 versus PEEPARDSnet. Setting PEEP according to a PEEPDECREMENTAL trial after a recruitment maneuver (21 ± 4 cm H2O, P = 0.99 vs. PEEPINCREMENTAL) further lowered lung elastance (19 ± 6 cm H2O/l) and increased oxygenation (329 ± 82 mmHg) while reducing lung collapse (9 ± 2%) and overdistension (11 ± 2%), all values P < 0.05 versus PEEPARDSnet and PEEPINCREMENTAL. All patients were maintained on titrated PEEP levels up to 24 h without hemodynamic or ventilation related complications. CONCLUSIONS: Among the PEEP titration strategies tested, setting PEEP according to a PEEPDECREMENTAL trial preceded by a recruitment maneuver obtained the best lung function by decreasing lung overdistension and collapse, restoring lung elastance, and oxygenation suggesting lung tissue recruitment.
BACKGROUND:Obesepatients are characterized by normal chest-wall elastance and high pleural pressure and have been excluded from trials assessing best strategies to set positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS). The authors hypothesized that severely obesepatients with ARDS present with a high degree of lung collapse, reversible by titrated PEEP preceded by a lung recruitment maneuver. METHODS: Severely obese ARDSpatients were enrolled in a physiologic crossover study evaluating the effects of three PEEP titration strategies applied in the following order: (1) PEEPARDSNET: the low PEEP/FIO2 ARDSnet table; (2) PEEPINCREMENTAL: PEEP levels set to determine a positive end-expiratory transpulmonary pressure; and (3) PEEPDECREMENTAL: PEEP levels set to determine the lowest respiratory system elastance during a decremental PEEP trial following a recruitment maneuver on respiratory mechanics, regional lung collapse, and overdistension according to electrical impedance tomography and gas exchange. RESULTS: Fourteen patients underwent the study procedures. At PEEPARDSNET (13 ± 1 cm H2O) end-expiratory transpulmonary pressure was negative (-5 ± 5 cm H2O), lung elastance was 27 ± 12 cm H2O/L, and PaO2/FIO2 was 194 ± 111 mmHg. Compared to PEEPARDSNET, at PEEPINCREMENTAL level (22 ± 3 cm H2O) lung volume increased (977 ± 708 ml), lung elastance decreased (23 ± 7 cm H2O/l), lung collapse decreased (18 ± 10%), and ventilation homogeneity increased thus rising oxygenation (251 ± 105 mmHg), despite higher overdistension levels (16 ± 12%), all values P < 0.05 versus PEEPARDSnet. Setting PEEP according to a PEEPDECREMENTAL trial after a recruitment maneuver (21 ± 4 cm H2O, P = 0.99 vs. PEEPINCREMENTAL) further lowered lung elastance (19 ± 6 cm H2O/l) and increased oxygenation (329 ± 82 mmHg) while reducing lung collapse (9 ± 2%) and overdistension (11 ± 2%), all values P < 0.05 versus PEEPARDSnet and PEEPINCREMENTAL. All patients were maintained on titrated PEEP levels up to 24 h without hemodynamic or ventilation related complications. CONCLUSIONS: Among the PEEP titration strategies tested, setting PEEP according to a PEEPDECREMENTAL trial preceded by a recruitment maneuver obtained the best lung function by decreasing lung overdistension and collapse, restoring lung elastance, and oxygenation suggesting lung tissue recruitment.
Authors: Maria Plataki; Di Pan; Parag Goyal; Katherine Hoffman; Jacky Man Kwan Choi; Hao Huang; Monika M Safford; Edward J Schenck Journal: BMJ Open Respir Res Date: 2021-08
Authors: Francesco Zadek; Jonah Rubin; Luigi Grassi; Daniel Van Den Kroonenberg; Grant Larson; Martin Capriles; Roberta De Santis Santiago; Gaetano Florio; David A Imber; Edward A Bittner; Kathryn A Hibbert; Alex Legassey; Jeliene LaRocque; Gaston Cudemus-Deseda; Aranya Bagchi; Jerome Crowley; Kenneth Shelton; Robert Kacmarek; Lorenzo Berra Journal: Crit Care Explor Date: 2021-06-29
Authors: Gaetano Florio; Roberta Ribeiro De Santis Santiago; Jacopo Fumagalli; David A Imber; Francesco Marrazzo; Abraham Sonny; Aranya Bagchi; Angela K Fitch; Chika V Anekwe; Marcelo Britto Passos Amato; Pankaj Arora; Robert M Kacmarek; Lorenzo Berra Journal: Chest Date: 2021-05-08 Impact factor: 10.262
Authors: Anoopindar K Bhalla; Margaret J Klein; Guillaume Emeriaud; Yolanda M Lopez-Fernandez; Natalie Napolitano; Analia Fernandez; Awni M Al-Subu; Rainer Gedeit; Steven L Shein; Ryan Nofziger; Deyin Doreen Hsing; George Briassoulis; Stavroula Ilia; Florent Baudin; Byron Enrique Piñeres-Olave; Ledys Maria Izquierdo; John C Lin; Ira M Cheifetz; Martin C J Kneyber; Lincoln Smith; Robinder G Khemani; Christopher J L Newth Journal: Crit Care Med Date: 2021-10-01 Impact factor: 9.296
Authors: Audrey De Jong; Hermann Wrigge; Goran Hedenstierna; Luciano Gattinoni; Davide Chiumello; Jean-Pierre Frat; Lorenzo Ball; Miet Schetz; Peter Pickkers; Samir Jaber Journal: Intensive Care Med Date: 2020-10-23 Impact factor: 17.440