tetano
Editor, Senior Moderator
Chest
. 2021 Oct 16;S0012-3692(21)04100-3.
doi: 10.1016/j.chest.2021.10.012. Online ahead of print.
Lung response to a higher positive end-expiratory pressure in mechanically ventilated patients with COVID-19
Alessandro Protti[SUP] 1 [/SUP], Alessandro Santini[SUP] 2 [/SUP], Francesca Pennati[SUP] 3 [/SUP], Chiara Chiurazzi[SUP] 2 [/SUP], Massimo Cressoni[SUP] 4 [/SUP], Michele Ferrari[SUP] 2 [/SUP], Giacomo E Iapichino[SUP] 2 [/SUP], Luca Carenzo[SUP] 2 [/SUP], Ezio Lanza[SUP] 5 [/SUP], Giorgio Picardo[SUP] 6 [/SUP], Pietro Caironi[SUP] 7 [/SUP], Andrea Aliverti[SUP] 3 [/SUP], Maurizio Cecconi[SUP] 8 [/SUP]
Affiliations
Abstract
Background: International guidelines suggest using a higher (>10 cmH[SUB]2[/SUB]O) positive end-expiratory pressure (PEEP) in patients with moderate-to-severe acute respiratory distress syndrome (ARDS) due to the novel coronavirus disease (COVID-19). However, even if oxygenation generally improves with a higher PEEP, compliance and arterial carbon dioxide tension (PaCO[SUB]2[/SUB]) frequently do not, as if recruitment was small.
Research question: Is the potential for lung recruitment small in patients with early ARDS due to COVID-19?
Study design and methods: Forty patients with ARDS due to COVID-19 were studied in the supine position within three days of endotracheal intubation. They all underwent a PEEP trial, where oxygenation, compliance, and PaCO[SUB]2[/SUB] were measured with 5, 10, and 15 cmH[SUB]2[/SUB]O of PEEP and all other ventilatory settings unchanged. Twenty underwent a whole-lung static computed tomography at 5 and 45 cmH[SUB]2[/SUB]O, and the other twenty at 5 and 15 cmH[SUB]2[/SUB]O of airway pressure. Recruitment and hyperinflation were defined as a decrease in the volume of the non-aerated (density above -100 HU) and an increase in the volume of the over-aerated (density below -900 HU) lung compartments, respectively.
Results: From 5 to 15 cmH[SUB]2[/SUB]O, oxygenation improved in thirty-six (90%) patients but compliance only in eleven (28%) and PaCO[SUB]2[/SUB] only in fourteen (35%). From 5 to 45 cmH[SUB]2[/SUB]O, recruitment was 351 (161-462) ml and hyperinflation 465 (220-681) ml. From 5 to 15 cmH[SUB]2[/SUB]O, recruitment was 168 (110-202) ml and hyperinflation 121 (63-270) ml. Hyperinflation variably developed in all patients and exceeded recruitment in more than half of them.
Interpretation: Patients with early ARDS due to COVID-19, ventilated in the supine position, present with a large potential for lung recruitment. Even so, their compliance and PaCO[SUB]2[/SUB] do not generally improve with a higher PEEP, possibly due to hyperinflation.
Keywords: acute respiratory distress syndrome; coronavirus disease 2019; mechanical ventilation; positive end-expiratory pressure.
. 2021 Oct 16;S0012-3692(21)04100-3.
doi: 10.1016/j.chest.2021.10.012. Online ahead of print.
Lung response to a higher positive end-expiratory pressure in mechanically ventilated patients with COVID-19
Alessandro Protti[SUP] 1 [/SUP], Alessandro Santini[SUP] 2 [/SUP], Francesca Pennati[SUP] 3 [/SUP], Chiara Chiurazzi[SUP] 2 [/SUP], Massimo Cressoni[SUP] 4 [/SUP], Michele Ferrari[SUP] 2 [/SUP], Giacomo E Iapichino[SUP] 2 [/SUP], Luca Carenzo[SUP] 2 [/SUP], Ezio Lanza[SUP] 5 [/SUP], Giorgio Picardo[SUP] 6 [/SUP], Pietro Caironi[SUP] 7 [/SUP], Andrea Aliverti[SUP] 3 [/SUP], Maurizio Cecconi[SUP] 8 [/SUP]
Affiliations
- PMID: 34666011
- DOI: 10.1016/j.chest.2021.10.012
Abstract
Background: International guidelines suggest using a higher (>10 cmH[SUB]2[/SUB]O) positive end-expiratory pressure (PEEP) in patients with moderate-to-severe acute respiratory distress syndrome (ARDS) due to the novel coronavirus disease (COVID-19). However, even if oxygenation generally improves with a higher PEEP, compliance and arterial carbon dioxide tension (PaCO[SUB]2[/SUB]) frequently do not, as if recruitment was small.
Research question: Is the potential for lung recruitment small in patients with early ARDS due to COVID-19?
Study design and methods: Forty patients with ARDS due to COVID-19 were studied in the supine position within three days of endotracheal intubation. They all underwent a PEEP trial, where oxygenation, compliance, and PaCO[SUB]2[/SUB] were measured with 5, 10, and 15 cmH[SUB]2[/SUB]O of PEEP and all other ventilatory settings unchanged. Twenty underwent a whole-lung static computed tomography at 5 and 45 cmH[SUB]2[/SUB]O, and the other twenty at 5 and 15 cmH[SUB]2[/SUB]O of airway pressure. Recruitment and hyperinflation were defined as a decrease in the volume of the non-aerated (density above -100 HU) and an increase in the volume of the over-aerated (density below -900 HU) lung compartments, respectively.
Results: From 5 to 15 cmH[SUB]2[/SUB]O, oxygenation improved in thirty-six (90%) patients but compliance only in eleven (28%) and PaCO[SUB]2[/SUB] only in fourteen (35%). From 5 to 45 cmH[SUB]2[/SUB]O, recruitment was 351 (161-462) ml and hyperinflation 465 (220-681) ml. From 5 to 15 cmH[SUB]2[/SUB]O, recruitment was 168 (110-202) ml and hyperinflation 121 (63-270) ml. Hyperinflation variably developed in all patients and exceeded recruitment in more than half of them.
Interpretation: Patients with early ARDS due to COVID-19, ventilated in the supine position, present with a large potential for lung recruitment. Even so, their compliance and PaCO[SUB]2[/SUB] do not generally improve with a higher PEEP, possibly due to hyperinflation.
Keywords: acute respiratory distress syndrome; coronavirus disease 2019; mechanical ventilation; positive end-expiratory pressure.