Personalized PEEP in spontaneously breathing patients with ARDS by simultaneous EIT and transpulmonary pressure monitoring: a randomized crossover....
Javier Amador-Casta?eda, BHS, RRT, FCCM
| Respiratory Care Practitioner | Author | Speaker | Veteran | ESICM Representative, North America
Mauri, T., Grieco, D.L., Spinelli, E. et al. 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. Intensive Care Med (2024). https://doi.org/10.1007/s00134-024-07695-y
Summary of "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"
Summary:
This study investigates the physiological benefits of personalized positive end-expiratory pressure (PEEP) in spontaneously breathing ARDS patients undergoing pressure support ventilation (PSV). By using electrical impedance tomography (EIT) and transpulmonary pressure (?PL) monitoring, the study compares personalized PEEP settings (PEEPEIT-?PL) with traditional PEEP/FiO2 table methods. Personalized PEEP reduced lung stress, work of breathing, and respiratory drive while improving lung mechanics and alveolar recruitment without increasing overdistension.
Key Points:
1. Study Population: Thirty ARDS patients, intubated for a median of six days and on PSV for three days, participated in the randomized crossover trial.
2. PEEP Personalization Method: PEEPEIT-?PL minimized lung overdistension and collapse using synchronized EIT and transpulmonary pressure monitoring.
3. Improved Lung Mechanics: PEEPEIT-?PL resulted in reduced dynamic lung stress and improved compliance compared to traditional PEEP.
4. Reduced Work of Breathing: The method decreased inspiratory muscular pressure and the pressure–time product, indicating reduced respiratory effort.
5. Respiratory Drive Benefits: Patients exhibited a lower airway occlusion pressure (P0.1), suggesting reduced drive to breathe under PEEPEIT-?PL.
6. Alveolar Recruitment: PEEPEIT-?PL led to higher alveolar recruitment while avoiding significant overdistension.
7. Subgroup Insights: Patients with higher baseline alveolar recruitability and oxygenation derived the greatest benefit from personalized PEEP.
8. Alternative Approaches: Simple bedside methods, such as P0.1-based PEEP selection, showed partial agreement with PEEPEIT-?PL but lacked precision.
9. Safety and Tolerance: The study reported no adverse effects, highlighting the feasibility of personalized PEEP in clinical settings.
10. Future Implications: The findings support incorporating personalized PEEP strategies into ARDS care to improve lung and diaphragm protection.
Conclusion:
Personalized PEEP settings guided by EIT and transpulmonary pressure monitoring provide physiological benefits in spontaneously breathing ARDS patients undergoing PSV. By optimizing lung and diaphragm protection without increasing overdistension, this approach represents a promising alternative to traditional methods. Further studies are needed to validate its impact on long-term outcomes.
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Discussion Questions:
1. How can personalized PEEP strategies be integrated into routine ARDS management to improve patient outcomes?
2. What are the limitations of EIT and transpulmonary pressure monitoring in broader clinical adoption, and how might they be addressed?
3. How can simplified bedside methods for PEEP personalization be improved to match the precision of advanced monitoring systems?
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