Positive End-Expiratory Pressure and Respiratory Rate Modify the Association of Mechanical Power and Driving Pressure With Mortality Among Patients With Acute Respiratory Distress Syndrome

Background: Different positive end-expiratory pressure (PEEP) strategies are available for subjects with coronavirus disease 2019 (COVID-19)–induced acute respiratory distress syndrome (ARDS) requiring invasive mechanical ventilation. We aimed to evaluate three conventional PEEP strategies on their effects on respiratory mechanics, gas exchanges, and hemodynamics.Methods: This is a prospective, physiologic, multicenter study conducted in China. We recruited 20 intubated subjects with ARDS and confirmed COVID-19. We first set PEEP by the ARDSnet low PEEP–fraction of inspired oxygen (FIO2) table. After a recruitment maneuver, PEEP was set at 15, 10, and 5 cm H2O for 10 min, respectively. Among these three PEEP levels, best-compliance PEEP was the one providing the highest respiratory system compliance; best-oxygenation PEEP was the one providing the highest PaO2 (partial pressure of arterial oxygen)/FIO2.Results: At each PEEP level, we assessed respiratory mechanics, arterial blood gas, and hemodynamics. Among three PEEP levels, plateau pressure, driving pressure, mechanical power, and blood pressure improved with lower PEEP. The ARDSnet low PEEP–FIO2 table and the best-oxygenation strategies provided higher PEEP than the best-compliance strategy (11 ± 6 cm H2O vs. 11 ± 3 cm H2O vs. 6 ± 2 cm H2O, p = 0.001), leading to higher plateau pressure, driving pressure, and mechanical power. The three PEEP strategies were not significantly different in gas exchange. The subgroup analysis showed that three PEEP strategies generated different effects in subjects with moderate or severe ARDS (n = 12) but not in subjects with mild ARDS (n = 8).Conclusions: In our cohort with COVID-19–induced ARDS, the ARDSnet low PEEP/FIO2 table and the best-oxygenation strategies led to higher PEEP and potentially higher risk of ventilator-induced lung injury than the best-compliance strategy.Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT04359251.

Download Full-text

Physiological Effects of the Open Lung Approach in Patients with Early, Mild, Diffuse Acute Respiratory Distress Syndrome

Anesthesiology ◽

10.1097/aln.0000000000000862 ◽

2015 ◽

Vol 123 (5) ◽

pp. 1113-1121 ◽

Cited By ~ 38

Author(s):

Gilda Cinnella ◽

Salvatore Grasso ◽

Pasquale Raimondo ◽

Davide D’Antini ◽

Lucia Mirabella ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Tidal Volume ◽

Distress Syndrome ◽

Driving Pressure ◽

Lung Mechanics ◽

Positive End Expiratory Pressure ◽

Open Lung ◽

Open Lung Approach

Abstract Background To test the hypothesis that in early, mild, acute respiratory distress syndrome (ARDS) patients with diffuse loss of aeration, the application of the open lung approach (OLA) would improve homogeneity in lung aeration and lung mechanics, without affecting hemodynamics. Methods Patients were ventilated according to the ARDS Network protocol at baseline (pre-OLA). OLA consisted in a recruitment maneuver followed by a decremental positive end-expiratory pressure trial. Respiratory mechanics, gas exchange, electrical impedance tomography (EIT), cardiac index, and stroke volume variation were measured at baseline and 20 min after OLA implementation (post-OLA). Esophageal pressure was used for lung and chest wall elastance partitioning. The tomographic lung image obtained at the fifth intercostal space by EIT was divided in two ventral and two dorsal regions of interest (ROIventral and ROIDorsal). Results Fifteen consecutive patients were studied. The OLA increased arterial oxygen partial pressure/inspired oxygen fraction from 216 ± 13 to 311 ± 19 mmHg (P < 0.001) and decreased elastance of the respiratory system from 29.4 ± 3 cm H2O/l to 23.6 ± 1.7 cm H2O/l (P < 0.01). The driving pressure (airway opening plateau pressure − total positive end-expiratory pressure) decreased from 17.9 ± 1.5 cm H2O pre-OLA to 15.4 ± 2.1 post-OLA (P < 0.05). The tidal volume fraction reaching the dorsal ROIs increased, and consequently the ROIVentral/Dorsal impedance tidal variation decreased from 2.01 ± 0.36 to 1.19 ± 0.1 (P < 0.01). Conclusions The OLA decreases the driving pressure and improves the oxygenation and lung mechanics in patients with early, mild, diffuse ARDS. EIT is useful to assess the impact of OLA on regional tidal volume distribution.

Download Full-text

Inflammatory Biomarkers And Changes In Driving Pressure With Positive End-Expiratory Pressure In Acute Respiratory Distress Syndrome

10.1164/ajrccm-conference.2011.183.1_meetingabstracts.a1156 ◽

2011 ◽

Author(s):

Angela J. Frank ◽

Ednan Bajwa ◽

Roy Brower ◽

Marcelo B. Amato ◽

B. T. Thompson ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Driving Pressure ◽

Inflammatory Biomarkers ◽

Positive End Expiratory Pressure

Download Full-text

Mechanical power in pediatric acute respiratory distress syndrome: a PARDIE study

Critical Care ◽

10.1186/s13054-021-03853-6 ◽

2022 ◽

Vol 26 (1) ◽

Author(s):

Anoopindar K. Bhalla ◽

Margaret J. Klein ◽

Vicent Modesto I Alapont ◽

Guillaume Emeriaud ◽

Martin C. J. Kneyber ◽

...

Keyword(s):

Mechanical Ventilation ◽

Acute Respiratory Distress Syndrome ◽

Intensive Care ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Mechanical Power ◽

Positive End Expiratory Pressure ◽

Ventilator Management ◽

Ventilation Management

Abstract Background Mechanical power is a composite variable for energy transmitted to the respiratory system over time that may better capture risk for ventilator-induced lung injury than individual ventilator management components. We sought to evaluate if mechanical ventilation management with a high mechanical power is associated with fewer ventilator-free days (VFD) in children with pediatric acute respiratory distress syndrome (PARDS). Methods Retrospective analysis of a prospective observational international cohort study. Results There were 306 children from 55 pediatric intensive care units included. High mechanical power was associated with younger age, higher oxygenation index, a comorbid condition of bronchopulmonary dysplasia, higher tidal volume, higher delta pressure (peak inspiratory pressure—positive end-expiratory pressure), and higher respiratory rate. Higher mechanical power was associated with fewer 28-day VFD after controlling for confounding variables (per 0.1 J·min−1·Kg−1 Subdistribution Hazard Ratio (SHR) 0.93 (0.87, 0.98), p = 0.013). Higher mechanical power was not associated with higher intensive care unit mortality in multivariable analysis in the entire cohort (per 0.1 J·min−1·Kg−1 OR 1.12 [0.94, 1.32], p = 0.20). But was associated with higher mortality when excluding children who died due to neurologic reasons (per 0.1 J·min−1·Kg−1 OR 1.22 [1.01, 1.46], p = 0.036). In subgroup analyses by age, the association between higher mechanical power and fewer 28-day VFD remained only in children < 2-years-old (per 0.1 J·min−1·Kg−1 SHR 0.89 (0.82, 0.96), p = 0.005). Younger children were managed with lower tidal volume, higher delta pressure, higher respiratory rate, lower positive end-expiratory pressure, and higher PCO2 than older children. No individual ventilator management component mediated the effect of mechanical power on 28-day VFD. Conclusions Higher mechanical power is associated with fewer 28-day VFDs in children with PARDS. This association is strongest in children < 2-years-old in whom there are notable differences in mechanical ventilation management. While further validation is needed, these data highlight that ventilator management is associated with outcome in children with PARDS, and there may be subgroups of children with higher potential benefit from strategies to improve lung-protective ventilation. Take Home Message: Higher mechanical power is associated with fewer 28-day ventilator-free days in children with pediatric acute respiratory distress syndrome. This association is strongest in children <2-years-old in whom there are notable differences in mechanical ventilation management.

Download Full-text

Driving pressure y mortalidad en el síndrome de distrés respiratorio agudo

Revista Electrónica AnestesiaR ◽

10.30445/rear.v11i8.765 ◽

2019 ◽

Vol 11 (8) ◽

pp. 2

Author(s):

Isabel de la Calle Gil ◽

Rosalía Navarro Casado ◽

Raquel García Álvarez

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Protective Ventilation ◽

Alveolar Recruitment ◽

Driving Pressure ◽

Lung Protective Ventilation ◽

Positive End Expiratory Pressure ◽

Current Guidelines

Las actuales guías de manejo del síndrome de distrés respiratorio agudo (SDRA) recomiendan una ventilación protectora: volumen corriente bajo, presión positiva al final de la espiración (PEEP) adecuada y maniobras de reclutamiento alveolar. Sin embargo, estudios recientes han mostrado que la driving pressure podría ser la variable que mejor se correlaciona con la supervivencia en pacientes con SDRA. ABSTRACT Driving pressure and mortality in acute respiratory distress syndrome Current guidelines for ventilation in patients with acute respiratory distress syndrome (ARDS) recommend lung-protective ventilation: use of low tidal volumes, appropiate positive end-expiratory pressure and alveolar recruitment maneuvers. However, recent studies have shown that driving pressure could be the variable that best correlated with survival in patients with ARDS.

Download Full-text

Driving Pressure for Ventilation of Patients with Acute Respiratory Distress Syndrome

Anesthesiology ◽

10.1097/aln.0000000000003195 ◽

2020 ◽

Vol 132 (6) ◽

pp. 1569-1576 ◽

Cited By ~ 1

Author(s):

Angela Meier ◽

Rebecca E. Sell ◽

Atul Malhotra

Keyword(s):

Mechanical Ventilation ◽

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Plateau Pressure ◽

Driving Pressure ◽

Positive End Expiratory Pressure

Measuring driving pressure (defined by plateau pressure minus positive end-expiratory pressure) is a useful addition to existing variables when setting mechanical ventilation, particularly in the acute respiratory distress syndrome.

Download Full-text