Lung Response to a Higher Positive End-Expiratory Pressure in Mechanically Ventilated Patients With COVID-19

Alessandro Protti, Alessandro Santini, Francesca Pennati, Chiara Chiurazzi, Massimo Cressoni, Michele Ferrari, Giacomo E Iapichino, Luca Carenzo, Ezio Lanza, Giorgio Picardo, Pietro Caironi, Andrea Aliverti, Maurizio Cecconi, Alessandro Protti, Alessandro Santini, Francesca Pennati, Chiara Chiurazzi, Massimo Cressoni, Michele Ferrari, Giacomo E Iapichino, Luca Carenzo, Ezio Lanza, Giorgio Picardo, Pietro Caironi, Andrea Aliverti, Maurizio Cecconi

Abstract

Background: International guidelines suggest using a higher (> 10 cm H2O) positive end-expiratory pressure (PEEP) in patients with moderate-to-severe ARDS due to COVID-19. However, even if oxygenation generally improves with a higher PEEP, compliance, and Paco2 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 3 days of endotracheal intubation. They all underwent a PEEP trial, in which oxygenation, compliance, and Paco2 were measured with 5, 10, and 15 cm H2O of PEEP, and all other ventilatory settings unchanged. Twenty underwent a whole-lung static CT scan at 5 and 45 cm H2O, and the other 20 at 5 and 15 cm H2O 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 cm H2O, oxygenation improved in 36 (90%) patients but compliance only in 11 (28%) and Paco2 only in 14 (35%). From 5 to 45 cm H2O, recruitment was 351 (161-462) mL and hyperinflation 465 (220-681) mL. From 5 to 15 cm H2O, 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 Paco2 do not generally improve with a higher PEEP, possibly because of hyperinflation.

Keywords: acute respiratory distress syndrome; coronavirus disease 2019; mechanical ventilation; positive end-expiratory pressure.

Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

Figures

Graphical abstract
Graphical abstract
Figure 1
Figure 1
The functional response to a higher PEEP. Gas exchange and respiratory system compliance were measured with 5, 10, and 15 cm H2O of positive end-expiratory pressure (PEEP) while other ventilatory settings were kept constant (the so-called “PEEP trial”). Herein we show individual data recorded with the three different levels of PEEP and the group median values (red bars). Pao2 = arterial tension of oxygen. Fio2 = inspiratory fraction of oxygen. The compliance was the ratio of tidal volume to driving airway pressure, the difference between plateau airway pressure and total PEEP. P-values refer to the overall Friedman’s test (above), and the posthoc Wilcoxon signed rank-sum test, corrected with Bonferroni's method (below).
Figure 2
Figure 2
Lung volume distribution of CT densities at 5, 15, or 45 cm H2O of airway pressure. Forty patients with COVID-19 underwent a lung CT at 5 cm H2O of airway pressure. Twenty of them had a second CT taken at 15 cm H2O, and the other 20 at 45 cm H2O of airway pressure. Herein we show the individual and median distributions of lung volume (tissue and gas) as a function of the physical densities measured in Hounsfield units (HU). With a higher pressure, volumes with density above −100 HU (non-aerated) decreased, as for alveolar recruitment, whereas those with density from −500 to −900 (normally aerated) increased, as for better aeration. Volumes with a density below −900 HU (over-aerated) simultaneously increased, as for hyperinflation. Volumes with a density from −800 to −900 HU, which can become over-aerated after tidal inflation, increased as well. The over-aerated compartment in some patients at 5 or 15 cm H2O was larger than in others at 45 cm H2O of airway pressure (see also e-Fig 4).
Figure 3
Figure 3
Color-coded analysis of lung CT data. Representative CT images taken at the level of carina at 5 and 45 cm H2O of airway pressure from three patients with COVID-19 and very different degrees of recruitment and hyperinflation. Upper panels: original lung CT images, with aeration shown on a continuous grayscale. Lower panels: using an automated encoding system, we attributed a specific color to the non-aerated, poorly aerated, normally aerated, and over-aerated compartments. Left panels: recruitment 457 mL and hyperinflation 5 mL. With 5 cm H2O of PEEP, maximal superimposed pressure was 13.4 cm H2O; compliance 27 mL/cm H2O; Pao2:Fio2 90 mm Hg. C-reactive protein at ICU admission was 20 mg/dL. Central panels: recruitment 347 mL and hyperinflation 661 mL. Maximal superimposed pressure 11.5 cm H2O; compliance 44 mL/cm H2O; Pao2:Fio2 104 mm Hg. C-reactive protein 10 mg/dL. Right panels: recruitment 160 mL and hyperinflation 993 mL. Maximal superimposed pressure 9.4 cm H2O; compliance 60 mL/cm H2O; Pao2:Fio2 80 mm Hg. C-reactive protein 1 mg/dL. None of these patients had a history of COPD or was obese.

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