Best PEEP trials are dependent on tidal volume

Abstract

Determining the optimal positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome remains an area of active investigation. Most trials individualizing PEEP optimize one physiologic parameter (e.g., driving pressure) by titrating PEEP while holding other ventilator settings constant. Optimal PEEP, however, may depend on the tidal volume, and changing the tidal volume with which a best PEEP trial is performed may lead to different best PEEP settings in the same patient.

Trial registration: ClinicalTrials.gov, NCT02871102. Registered on 12 August 2016.

Conflict of interest statement

Ethics approval and consent to participate

The study was approved by the Vanderbilt University Institutional Review Board (IRB# 160770) with informed consent obtained by patient surrogate.

Competing interests

Maquet was given the opportunity to review the manuscript prior to submission to ensure the absence of Maquet Confidential Information. The authors declare that they have no potential conflicts of interest.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1

Point of maximal compliance depends on tidal volume used in PEEP trial. Plotted markers represent static compliance of respiratory system (CRS) at each PEEP level during a decremental PEEP trial for a single patient. Marker shapes correspond to measured stress index for the PEEP–tidal volume pairing, and marker color corresponds to tidal volume. Loess curve connects points with identical tidal volumes. Vertical lines indicate the PEEP selected by ART protocol for a given tidal volume. PBW predicted body weight, PEEP positive end-expiratory pressure

Fig. 2

Point of minimal driving pressure depends on tidal volume used in PEEP trial. Plotted markers are measured driving pressure at each PEEP level for a given tidal volume. Marker shapes coded by stress index, and superimposed loess lines show estimated driving pressure over the range of PEEP by tidal volume. Corresponding vertical lines indicate the PEEP selected by ART protocol for a given tidal volume. PBW predicted body weight, PEEP positive end-expiratory pressure