PEEP titration during prone positioning for acute respiratory distress syndrome

Jeremy R Beitler, Claude Guérin, Louis Ayzac, Jordi Mancebo, Dina M Bates, Atul Malhotra, Daniel Talmor, Jeremy R Beitler, Claude Guérin, Louis Ayzac, Jordi Mancebo, Dina M Bates, Atul Malhotra, Daniel Talmor

Abstract

No major trial evaluating prone positioning for acute respiratory distress syndrome (ARDS) has incorporated a high-positive end-expiratory pressure (high-PEEP) strategy despite complementary physiological rationales. We evaluated generalizability of three recent proning trials to patients receiving a high-PEEP strategy. All trials employed a relatively low-PEEP strategy. After protocol ventilator settings were initiated and the patient was positioned per treatment assignment, post-intervention PEEP was not more than 5 cm H2O in 16.7 % and not more than 10 cm H2O in 66.0 % of patients. Post-intervention PEEP would have been nearly twice the set PEEP had a high-PEEP strategy been employed. Use of either proning or high-PEEP likely improves survival in moderate-severe ARDS; the role for both concomitantly remains unknown.

Figures

Fig. 1
Fig. 1
Comparison of set PEEP used in proning clinical trials and hypothetical PEEP that would have been required under the ALVEOLI or LOVS high-PEEP protocols. Expected PEEP under high-PEEP protocols was calculated by using individual patient FiO2 values. When the study protocol permitted multiple PEEP levels for a given FiO2, the lowest PEEP value was chosen to bias results toward smaller difference between set and expected PEEP. a Baseline PEEP values prior to study intervention. b First post-intervention PEEP values. Column height and error bars represent mean and standard deviation, respectively. #Significantly different than set PEEP at P < 0.05. ALVEOLI ARDS Network Assessment of Low tidal Volume and elevated End-expiratory volume to Obviate Lung Injury Trial, FiO2 fraction of inspired oxygen, LOVS Lung Open Ventilation Study, PEEP positive end-expiratory pressure

References

    1. Piehl MA, Brown RS. Use of extreme position changes in acute respiratory failure. Crit Care Med. 1976;4:13–14. doi: 10.1097/00003246-197601000-00003.
    1. Gattinoni L, Pesenti A, Carlesso E. Body position changes redistribute lung computed-tomographic density in patients with acute respiratory failure: impact and clinical fallout through the following 20 years. Intensive Care Med. 2013;39:1909–1915. doi: 10.1007/s00134-013-3066-x.
    1. Chiumello D, Taccone P, Berto V, Marino A, Migliara G, Lazzerini M, et al. Long-term outcomes in survivors of acute respiratory distress syndrome ventilated in supine or prone position. Intensive Care Med. 2012;38:221–229. doi: 10.1007/s00134-011-2445-4.
    1. Pappert D, Rossaint R, Slama K, Grüning T, Falke KJ. Influence of positioning on ventilation-perfusion relationships in severe adult respiratory distress syndrome. Chest. 1994;106:1511–1516. doi: 10.1378/chest.106.5.1511.
    1. Pelosi P, Tubiolo D, Mascheroni D, Vicardi P, Crotti S, Valenza F, et al. Effects of the prone position on respiratory mechanics and gas exchange during acute lung injury. Am J Respir Crit Care Med. 1998;157:387–393. doi: 10.1164/ajrccm.157.2.97-04023.
    1. Lai-Fook SJ, Rodarte JR. Pleural pressure distribution and its relationship to lung volume and interstitial pressure. J Appl Physiol. 1991;70:967–978.
    1. Mutoh T, Guest RJ, Lamm WJ, Albert RK. Prone position alters the effect of volume overload on regional pleural pressures and improves hypoxemia in pigs in vivo. Am Rev Respir Dis. 1992;146:300–306. doi: 10.1164/ajrccm/146.2.300.
    1. Mackenzie CF. Anatomy, physiology, and pathology of the prone position and postural drainage. Crit Care Med. 2001;29:1084–1085. doi: 10.1097/00003246-200105000-00046.
    1. Guerin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368:2159–2168. doi: 10.1056/NEJMoa1214103.
    1. Gattinoni L, Tognoni G, Pesenti A, Taccone P, Mascheroni D, Labarta V, et al. Effect of prone positioning on the survival of patients with acute respiratory failure. N Engl J Med. 2001;345:568–573. doi: 10.1056/NEJMoa010043.
    1. Guerin C, Gaillard S, Lemasson S, Ayzac L, Girard R, Beuret P, et al. Effects of systematic prone positioning in hypoxemic acute respiratory failure: a randomized controlled trial. JAMA. 2004;292:2379–2387. doi: 10.1001/jama.292.19.2379.
    1. Voggenreiter G, Aufmkolk M, Stiletto RJ, Baacke MG, Waydhas C, Ose C, et al. Prone positioning improves oxygenation in post-traumatic lung injury—a prospective randomized trial. J Trauma. 2005;59:333–341. doi: 10.1097/01.ta.0000179952.95921.49.
    1. Mancebo J, Fernández R, Blanch L, Rialp G, Gordo F, Ferrer M, et al. A multicenter trial of prolonged prone ventilation in severe acute respiratory distress syndrome. Am J Respir Crit Care Med. 2006;173:1233–1239. doi: 10.1164/rccm.200503-353OC.
    1. Fernández R, Trenchs X, Klamburg J, Castedo J, Serrano JM, Besso G, et al. Prone positioning in acute respiratory distress syndrome: a multicenter randomized clinical trial. Intensive Care Med. 2008;34:1487–1491. doi: 10.1007/s00134-008-1119-3.
    1. Taccone P, Pesenti A, Latini R, Polli F, Vagginelli F, Mietto C, et al. Prone positioning in patients with moderate and severe acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2009;302:1977–1984. doi: 10.1001/jama.2009.1614.
    1. Beitler JR, Shaefi S, Montesi SB, Devlin A, Loring SH, Talmor D, et al. Prone positioning reduces mortality from acute respiratory distress syndrome in the low tidal volume era: a meta-analysis. Intensive Care Med. 2014;40:332–341. doi: 10.1007/s00134-013-3194-3.
    1. Heart N. Lung, and Blood Institute ARDS Clinical Trials Network. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med. 2004;351:327–336. doi: 10.1056/NEJMoa032193.
    1. Meade MO, Cook DJ, Guyatt GH, Slutsky AS, Arabi YM, Cooper DJ, et al. Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2008;299:637–645. doi: 10.1001/jama.299.6.637.
    1. Mercat A, Richard JCM, Vielle B, Jaber S, Osman D, Diehl JL, et al. Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2008;299:646–655. doi: 10.1001/jama.299.6.646.
    1. Briel M, Meade M, Mercat A, Brower RG, Talmor D, Walter SD, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA. 2010;303:865–873. doi: 10.1001/jama.2010.218.
    1. Young D, Lamb SE, Shah S, MacKenzie I, Tunnicliffe W, Lall R, et al. High-frequency oscillation for acute respiratory distress syndrome. N Engl J Med. 2013;368:806–813. doi: 10.1056/NEJMoa1215716.
    1. Ferguson ND, Cook DJ, Guyatt GH, Mehta S, Hand L, Austin P, et al. High-frequency oscillation in early acute respiratory distress syndrome. N Engl J Med. 2013;368:795–805. doi: 10.1056/NEJMoa1215554.
    1. Fish E, Novack V, Banner-Goodspeed VM, Sarge T, Loring S, Talmor D. The Esophageal Pressure-Guided Ventilation 2 (EPVent2) trial protocol: a multicentre, randomised clinical trial of mechanical ventilation guided by transpulmonary pressure. BMJ Open. 2014;4:e006356. doi: 10.1136/bmjopen-2014-006356.
    1. Heart N. Lung, and Blood Institute ARDS Clinical Trials Network. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354:2564–2575. doi: 10.1056/NEJMoa062200.
    1. Rice TW, Wheeler AP, Thompson BT, DeBoisblanc BP, Steingrub J, Rock P. NHLBI ARDS Clinical Trials Network. Enteral omega-3 fatty acid, gamma-linolenic acid, and antioxidant supplementation in acute lung injury. JAMA. 2011;306:1574–1581. doi: 10.1001/jama.2011.1435.
    1. Rice TW, Wheeler AP, Thompson BT, Steingrub J, Hite RD, Moss M, et al. Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA. 2012;307:795–803. doi: 10.1001/jama.2011.1985.
    1. Matthay MA, Brower RG, Carson S, Douglas IS, Eisner M, Hite D, et al. Randomized, placebo-controlled clinical trial of an aerosolized β2-agonist for treatment of acute lung injury. Am J Respir Crit Care Med. 2011;184:561–568. doi: 10.1164/rccm.201012-2090OC.
    1. Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363:1107–1116. doi: 10.1056/NEJMoa1005372.
    1. Heart N, Lung, and Blood Institute ARDS Clinical Trials Network. Truwit JD, Bernard GR, Steingrub J, Matthay MA, Liu KD, Albertson TE, et al. Rosuvastatin for sepsis-associated acute respiratory distress syndrome. N Engl J Med. 2014;370:2191–2200. doi: 10.1056/NEJMoa1401520.
    1. Cornejo RA, Díaz JC, Tobar EA, Bruhn AR, Ramos CA, González RA, et al. Effects of prone positioning on lung protection in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2013;188:440–448. doi: 10.1164/rccm.201207-1279OC.
    1. Broccard AF, Shapiro RS, Schmitz LL, Ravenscraft SA, Marini JJ. Influence of prone position on the extent and distribution of lung injury in a high tidal volume oleic acid model of acute respiratory distress syndrome. Crit Care Med. 1997;25:16–27. doi: 10.1097/00003246-199701000-00007.
    1. Broccard A, Shapiro RS, Schmitz LL, Adams AB, Nahum A, Marini JJ. Prone positioning attenuates and redistributes ventilator-induced lung injury in dogs. Crit Care Med. 2000;28:295–303. doi: 10.1097/00003246-200002000-00001.
    1. Webb HH, Tierney DF. Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressures. Protection by positive end-expiratory pressure. Am Rev Respir Dis. 1974;110:556–565.
    1. Gainnier M, Michelet P, Thirion X, Arnal JM, Sainty JM, Papazian L. Prone position and positive end-expiratory pressure in acute respiratory distress syndrome. Crit Care Med. 2003;31:2719–2726. doi: 10.1097/01.CCM.0000094216.49129.4B.
    1. Gattinoni L, Taccone P, Carlesso E, Marini JJ. Prone position in acute respiratory distress syndrome. Rationale, indications, and limits. Am J Respir Crit Care Med. 2013;188:1286–1293. doi: 10.1164/rccm.201308-1532CI.
    1. Chiumello D, Cressoni M, Carlesso E, Caspani ML, Marino A, Gallazzi E, et al. Bedside selection of positive end-expiratory pressure in mild, moderate, and severe acute respiratory distress syndrome. Crit Care Med. 2014;42:252–264. doi: 10.1097/CCM.0b013e3182a6384f.
    1. Slutsky AS, Ranieri VM. Ventilator-induced lung injury. N Engl J Med. 2013;369:2126–2136. doi: 10.1056/NEJMra1208707.
    1. Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338:347–354. doi: 10.1056/NEJM199802053380602.
    1. Villar J, Kacmarek RM, Pérez-Méndez L, Aguirre-Jaime A. A high positive end-expiratory pressure, low tidal volume ventilatory strategy improves outcome in persistent acute respiratory distress syndrome: a randomized, controlled trial. Crit Care Med. 2006;34:1311–1318. doi: 10.1097/01.CCM.0000215598.84885.01.
    1. Talmor D, Sarge T, Malhotra A, O’Donnell CR, Ritz R, Lisbon A, et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med. 2008;359:2095–2104. doi: 10.1056/NEJMoa0708638.
    1. Suter PM, Fairley B, Isenberg MD. Optimum end-expiratory airway pressure in patients with acute pulmonary failure. N Engl J Med. 1975;292:284–289. doi: 10.1056/NEJM197502062920604.
    1. Pintado MC, de Pablo R, Trascasa M, Milicua JM, Rogero S, Daguerre M, et al. Individualized PEEP setting in subjects with ARDS: a randomized controlled pilot study. Respir Care. 2013;58:1416–1423. doi: 10.4187/respcare.02068.
    1. Amato MB, Meade MO, Slutsky AS, Brochard L, Costa EL, Schoenfeld DA, et al. Driving pressure and survival in acute respiratory distress syndrome. N Engl J Med. 2015;372:747–755. doi: 10.1056/NEJMsa1410639.
    1. Sarge T, Loring SH, Yitsak-Sade M, Malhotra A, Novack V, Talmor D. Raising positive end-expiratory pressures in ARDS to achieve a positive transpulmonary pressure does not cause hemodynamic compromise. Intensive Care Med. 2014;40:126–128. doi: 10.1007/s00134-013-3127-1.

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