Individualization of PEEP and tidal volume in ARDS patients with electrical impedance tomography: a pilot feasibility study

Tobias Becher, Valerie Buchholz, Daniel Hassel, Timo Meinel, Dirk Schädler, Inéz Frerichs, Norbert Weiler, Tobias Becher, Valerie Buchholz, Daniel Hassel, Timo Meinel, Dirk Schädler, Inéz Frerichs, Norbert Weiler

Abstract

Background: In mechanically ventilated patients with acute respiratory distress syndrome (ARDS), electrical impedance tomography (EIT) provides information on alveolar cycling and overdistension as well as assessment of recruitability at the bedside. We developed a protocol for individualization of positive end-expiratory pressure (PEEP) and tidal volume (VT) utilizing EIT-derived information on recruitability, overdistension and alveolar cycling. The aim of this study was to assess whether the EIT-based protocol allows individualization of ventilator settings without causing lung overdistension, and to evaluate its effects on respiratory system compliance, oxygenation and alveolar cycling.

Methods: 20 patients with ARDS were included. Initially, patients were ventilated according to the recommendations of the ARDS Network with a VT of 6 ml per kg predicted body weight and PEEP adjusted according to the lower PEEP/FiO2 table. Subsequently, ventilator settings were adjusted according to the EIT-based protocol once every 30 min for a duration of 4 h. To assess global overdistension, we determined whether lung stress and strain remained below 27 mbar and 2.0, respectively.

Results: Prospective optimization of mechanical ventilation with EIT led to higher PEEP levels (16.5 [14-18] mbar vs. 10 [8-10] mbar before optimization; p = 0.0001) and similar VT (5.7 ± 0.92 ml/kg vs. 5.8 ± 0.47 ml/kg before optimization; p = 0.96). Global lung stress remained below 27 mbar in all patients and global strain below 2.0 in 19 out of 20 patients. Compliance remained similar, while oxygenation was significantly improved and alveolar cycling was reduced after EIT-based optimization.

Conclusions: Adjustment of PEEP and VT using the EIT-based protocol led to individualization of ventilator settings with improved oxygenation and reduced alveolar cycling without promoting global overdistension. Trial registrationThis study was registered at clinicaltrials.gov (NCT02703012) on March 9, 2016 before including the first patient.

Keywords: Acute respiratory failure; Electrical impedance tomography; Lung-protective ventilation; Personalized medicine; Ventilator-induced lung injury.

Conflict of interest statement

DS and TB received lecture fees from Drägerwerk AG & Co. KGaA. The other authors report no competing interests.

Figures

Fig. 1
Fig. 1
Clinical protocol for prospective optimization of ventilator settings with electrical impedance tomography (EIT). Optimization started with an arterial blood gas (ABG) analysis and, if necessary, adjustments of respiratory rate (RR) and tidal volume (VT), followed by a recruitment maneuver (RM) and subsequent adaptations of positive end-expiratory pressure (PEEP) and VT. The footnotes are explained in the Additional file 1
Fig. 2
Fig. 2
Changes in positive end-expiratory pressure (PEEP), tidal volume (VT), elastance-based end-inspiratory transpulmonary pressure (Stress), ratio of arterial partial pressure of oxygen to inspired fraction of oxygen (PaO2/FiO2), transpulmonary driving pressure (ΔPTP) and strain after individualization of ventilator settings according to the electrical impedance tomography (EIT) protocol. ARDSNet = Ventilator settings according to acute respiratory distress syndrome network recommendations with low PEEP/FiO2 table; EIT = ventilator settings after 4 h of adjustment according to EIT-based protocol

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