Evaluation of Positive End-Expiratory Pressure Strategies in Patients With Coronavirus Disease 2019-Induced Acute Respiratory Distress Syndrome

Chun Pan, Cong Lu, Xiaobin She, Haibo Ren, Huazhang Wei, Liang Xu, Yingzi Huang, Jia'an Xia, Yuetian Yu, Lu Chen, Bin Du, Haibo Qiu, Chun Pan, Cong Lu, Xiaobin She, Haibo Ren, Huazhang Wei, Liang Xu, Yingzi Huang, Jia'an Xia, Yuetian Yu, Lu Chen, Bin Du, Haibo Qiu

Abstract

Background: Different positive end-expiratory pressure (PEEP) strategies are available for subjects with coronavirus disease 2019 (COVID-19)-induced acute respiratory distress syndrome (ARDS) requiring invasive mechanical ventilation. We aimed to evaluate three conventional PEEP strategies on their effects on respiratory mechanics, gas exchanges, and hemodynamics. Methods: This is a prospective, physiologic, multicenter study conducted in China. We recruited 20 intubated subjects with ARDS and confirmed COVID-19. We first set PEEP by the ARDSnet low PEEP-fraction of inspired oxygen (FIO2) table. After a recruitment maneuver, PEEP was set at 15, 10, and 5 cm H2O for 10 min, respectively. Among these three PEEP levels, best-compliance PEEP was the one providing the highest respiratory system compliance; best-oxygenation PEEP was the one providing the highest PaO2 (partial pressure of arterial oxygen)/FIO2. Results: At each PEEP level, we assessed respiratory mechanics, arterial blood gas, and hemodynamics. Among three PEEP levels, plateau pressure, driving pressure, mechanical power, and blood pressure improved with lower PEEP. The ARDSnet low PEEP-FIO2 table and the best-oxygenation strategies provided higher PEEP than the best-compliance strategy (11 ± 6 cm H2O vs. 11 ± 3 cm H2O vs. 6 ± 2 cm H2O, p = 0.001), leading to higher plateau pressure, driving pressure, and mechanical power. The three PEEP strategies were not significantly different in gas exchange. The subgroup analysis showed that three PEEP strategies generated different effects in subjects with moderate or severe ARDS (n = 12) but not in subjects with mild ARDS (n = 8). Conclusions: In our cohort with COVID-19-induced ARDS, the ARDSnet low PEEP/FIO2 table and the best-oxygenation strategies led to higher PEEP and potentially higher risk of ventilator-induced lung injury than the best-compliance strategy. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04359251.

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

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Pan, Lu, She, Ren, Wei, Xu, Huang, Xia, Yu, Chen, Du and Qiu.

Figures

Figure 1
Figure 1
Flow diagram.
Figure 2
Figure 2
Reponses to PEEP in all subjects (n = 20). *vs. PEEP 5 cm H2O, p < 0.05; †vs. PEEP 10 cm H2O, p < 0.05; ‡vs. oxygenation PEEP, p < 0.05; §vs. ARDSnet PEEP, p < 0.05.
Figure 3
Figure 3
Reponses to PEEP in subjects with mild ARDS (n = 8). *vs. PEEP 5 cm H2O, p <0.05; †vs. PEEP 10 cm H2O, p < 0.05; ‡vs. oxygenation PEEP, p < 0.05; §vs. ARDSnet PEEP, p < 0.05.
Figure 4
Figure 4
Reponses to PEEP in subjects with moderate or severe ARDS (n = 12). *vs. PEEP 5 cm H2O, p < 0.05; †vs. PEEP 10 cm H2O, p < 0.05; ‡vs. oxygenation PEEP, p < 0.05; §vs. ARDSnet PEEP, p < 0.05.

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