Intensive Care Medicine最新文献

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Personalized positive end-expiratory pressure in spontaneously breathing patients with acute respiratory distress syndrome by simultaneous electrical impedance tomography and transpulmonary pressure monitoring: a randomized crossover trial 通过同步电阻抗断层扫描和跨肺压力监测为急性呼吸窘迫综合征自主呼吸患者提供个性化呼气末正压：随机交叉试验

IF 38.9 1区医学 Q1 CRITICAL CARE MEDICINE

Intensive Care Medicine

Pub Date : 2024-11-11 DOI: 10.1007/s00134-024-07695-y

Tommaso Mauri, Domenico L. Grieco, Elena Spinelli, Marco Leali, Joaquin Perez, Valentina Chiavieri, Tommaso Rosà, Pierluigi Ferrara, Gaetano Scaramuzzo, Massimo Antonelli, Savino Spadaro, Giacomo Grasselli

Purpose

Personalized positive end-expiratory pressure (PEEP) might foster lung and diaphragm protection in patients with acute respiratory distress syndrome (ARDS) who are undergoing pressure support ventilation (PSV). We aimed to compare the physiologic effects of personalized PEEP set according to synchronized electrical impedance tomography (EIT) and driving transpulmonary pressure (∆PL) monitoring against a classical lower PEEP/FiO₂ table in intubated ARDS patients undergoing PSV.

Methods

A cross-over randomized multicenter study was conducted in 30 ARDS patients with simultaneous recording of the airway, esophageal and transpulmonary pressure, together with EIT during PSV. Following a decremental PEEP trial (18 cmH₂O to 4 cmH₂O), PEEP_EIT-∆PL was identified as the level with the smallest difference between lung overdistension and collapse. A low PEEP/FiO₂ table was used to select PEEP_TABLE. Each PEEP strategy was applied for 20 min, and physiologic data were collected at the end of each step.

Results

The PEEP trial was well tolerated. Median PEEP_EIT-∆PL was higher than PEEP_TABLE (10 [8–12] vs. 8 [5–10] cmH₂O; P = 0.021) and, at the individual patient level, PEEP_EIT-∆PL level differed from PEEP_TABLE in all patients. Overall, PEEP_EIT-∆PL was associated with lower dynamic ∆PL (P < 0.001) and pressure–time product (P < 0.001), but there was variability among patients. PEEP_EIT-∆PL also decreased respiratory drive and effort (P < 0.001), improved regional lung mechanics (P < 0.05) and reversed lung collapse (P = 0.007) without increasing overdistension (P = 0.695).

Conclusion

Personalized PEEP selected using synchronized EIT and transpulmonary pressure monitoring could be associated with reduced dynamic lung stress and metabolic work of breathing in ARDS patients undergoing PSV.

目的个性化呼气末正压（PEEP）可促进正在接受压力支持通气（PSV）的急性呼吸窘迫综合征（ARDS）患者的肺和膈肌保护。我们的目的是在接受 PSV 的插管 ARDS 患者中，比较根据同步电阻抗断层扫描（EIT）和肺动脉转压（ΔPL）监测设定的个性化 PEEP 与传统的较低 PEEP/FiO2 表的生理效果。方法在 30 名 ARDS 患者中开展了一项交叉随机多中心研究，在 PSV 期间同时记录气道、食道和肺动脉转压以及 EIT。经过递减 PEEP 试验（18 cmH2O 至 4 cmH2O），确定 PEEPEIT-∆PL 为肺过度张力与塌陷之间差异最小的水平。使用低 PEEP/FiO2 表选择 PEEPTABLE。每种 PEEP 策略应用 20 分钟，并在每个步骤结束时收集生理数据。中位 PEEPEIT-∆PL 高于 PEEPTABLE（10 [8-12] vs. 8 [5-10] cmH2O；P = 0.021），在患者个体水平上，所有患者的 PEEPEIT-∆PL 水平均不同于 PEEPTABLE。总体而言，PEEPEIT-∆PL 与较低的动态∆PL（P < 0.001）和压力-时间乘积（P < 0.001）相关，但患者之间存在差异。结论使用同步 EIT 和跨肺压力监测选择个性化 PEEP 可降低接受 PSV 治疗的 ARDS 患者的动态肺压力和呼吸代谢功。

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