Airway driving pressure and lung stress in ARDS patients

Davide Chiumello, Eleonora Carlesso, Matteo Brioni, Massimo Cressoni, Davide Chiumello, Eleonora Carlesso, Matteo Brioni, Massimo Cressoni

Abstract

Background: Lung-protective ventilation strategy suggests the use of low tidal volume, depending on ideal body weight, and adequate levels of PEEP. However, reducing tidal volume according to ideal body weight does not always prevent overstress and overstrain. On the contrary, titrating mechanical ventilation on airway driving pressure, computed as airway pressure changes from PEEP to end-inspiratory plateau pressure, equivalent to the ratio between the tidal volume and compliance of respiratory system, should better reflect lung injury. However, possible changes in chest wall elastance could affect the reliability of airway driving pressure. The aim of this study was to evaluate if airway driving pressure could accurately predict lung stress (the pressure generated into the lung due to PEEP and tidal volume).

Methods: One hundred and fifty ARDS patients were enrolled. At 5 and 15 cmH2O of PEEP, lung stress, driving pressure, lung and chest wall elastance were measured.

Results: The applied tidal volume (mL/kg of ideal body weight) was not related to lung gas volume (r (2) = 0.0005 p = 0.772). Patients were divided according to an airway driving pressure lower and equal/higher than 15 cmH2O (the lower and higher airway driving pressure groups). At both PEEP levels, the higher airway driving pressure group had a significantly higher lung stress, respiratory system and lung elastance compared to the lower airway driving pressure group. Airway driving pressure was significantly related to lung stress (r (2) = 0.581 p < 0.0001 and r (2) = 0.353 p < 0.0001 at 5 and 15 cmH2O of PEEP). For a lung stress of 24 and 26 cmH2O, the optimal cutoff value for the airway driving pressure were 15.0 cmH2O (ROC AUC 0.85, 95 % CI = 0.782-0.922); and 16.7 (ROC AUC 0.84, 95 % CI = 0.742-0.936).

Conclusions: Airway driving pressure can detect lung overstress with an acceptable accuracy. However, further studies are needed to establish if these limits could be used for ventilator settings.

Keywords: ARDS; Driving pressure; Esophageal pressure; Lung stress; Mortality; VILI.

Figures

Fig. 1
Fig. 1
Linear regression between lung gas volume at PEEP 5 cmH2O (determined at end-expiration with either lung CT scan or helium dilution technique) and actual body weight (upper panel) and ideal body weight (lower panel). PEEP positive end-expiratory pressure
Fig. 2
Fig. 2
Linear regression between tidal volume (mL/kg of ideal body weight) and lung gas volume at PEEP 5 cmH2O (mL). PEEP positive end-expiratory pressure
Fig. 3
Fig. 3
Linear regression between transpulmonary and airway driving pressure (cmH2O) at PEEP 5 (upper panel) and 15 cmH2O (lower panel). PEEP positive end-expiratory pressure
Fig. 4
Fig. 4
Linear regression between airway driving pressure (cmH2O) and lung stress (cmH2O) at PEEP 5 (upper panel) and 15 cmH2O (lower panel). PEEP positive end-expiratory pressure
Fig. 5
Fig. 5
Linear regression between lung stress (cmH2O) and the applied tidal volume (mL/kg of ideal body weight)
Fig. 6
Fig. 6
Receiver operator characteristic (ROC) curve for airway driving pressure as a predictor of lung stress above 24 (left panel) or 26 cmH2O (right panel). AUC area under the curve

References

    1. Ferguson ND, Fan E, Camporota L, Antonelli M, Anzueto A, Beale R, et al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med. 2012;38:1573–82. doi: 10.1007/s00134-012-2682-1.
    1. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342:1301–8.
    1. Amato MBP, Meade MO, Slutsky AS, Brochard L, Costa ELV, Schoenfeld DA, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372:747–55. doi: 10.1056/NEJMsa1410639.
    1. Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307:2526–33.
    1. Villar J, Kacmarek RM, Perez-Mendez 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;34:1311–8. doi: 10.1097/01.CCM.0000215598.84885.01.
    1. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39:165–228. doi: 10.1007/s00134-012-2769-8.
    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;303:865–73. doi: 10.1001/jama.2010.218.
    1. Slutsky AS, Ranieri VM. Ventilator-induced lung injury. N Engl J Med. 2013;369:2126–36. doi: 10.1056/NEJMra1208707.
    1. Wilson T. Solid mechanics. In: American Physiological Society, editor. Handbook of physiology: a critical, comprehensive presentation of physiological knowledge and concepts. Baltimore: Waverly Press; 1986. pp. 35–9.
    1. Kolobow T. Volutrauma, barotrauma, and ventilator-induced lung injury: lessons learned from the animal research laboratory. Crit Care Med. 2004;32:1961–2. doi: 10.1097/01.CCM.0000134405.71890.3A.
    1. Gattinoni L, Carlesso E, Cadringher P, Valenza F, Vagginelli F, Chiumello D. Physical and biological triggers of ventilator-induced lung injury and its prevention. Eur Respir J Suppl. 2003;47:15s–25s. doi: 10.1183/09031936.03.00021303.
    1. Gonzalez-Lopez A, Garcia-Prieto E, Batalla-Solis E, Amado-Rodriguez L, Avello N, Blanch L, et al. Lung strain and biological response in mechanically ventilated patients. Intensive Care Med. 2012;38:240–7. doi: 10.1007/s00134-011-2403-1.
    1. Protti A, Cressoni M, Santini A, Langer T, Mietto C, Febres D, et al. Lung stress and strain during mechanical ventilation: any safe threshold? Am J Respir Crit Care Med. 2011;183:1354–62. doi: 10.1164/rccm.201010-1757OC.
    1. Cressoni M, Gotti M, Chiurazzi C, Massari D, Algieri I, Amini M, et al. Mechanical power and development of ventilator-induced lung injury. Anesthesiology. 2016;124:1100–8. doi: 10.1097/ALN.0000000000001056.
    1. Terragni PP, Rosboch G, Tealdi A, Corno E, Menaldo E, Davini O, et al. Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome. Am J Respir Crit Care Med. 2007;175:160–6. doi: 10.1164/rccm.200607-915OC.
    1. Gattinoni L, Chiumello D, Carlesso E, Valenza F. Bench-to-bedside review: chest wall elastance in acute lung injury/acute respiratory distress syndrome patients. Crit Care Lond Engl. 2004;8:350–5. doi: 10.1186/cc2854.
    1. Cortes-Puentes GA, Cortes-Puentes LA, Adams AB, Anderson CP, Marini JJ, Dries DJ. Experimental intra-abdominal hypertension influences airway pressure limits for lung protective mechanical ventilation. J Trauma Acute Care Surg. 2013;74:1468–73. doi: 10.1097/TA.0b013e31829243a7.
    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;299:637–45. doi: 10.1001/jama.299.6.637.
    1. Mercat A, Richard J-CM, Vielle B, Jaber S, Osman D, Diehl J-L, et al. Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2008;299:646–55. doi: 10.1001/jama.299.6.646.
    1. Brower RG, Lanken PN, MacIntyre N, Matthay MA, Morris A, Ancukiewicz M, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med. 2004;351:327–36. doi: 10.1056/NEJMoa032193.
    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;359:2095–104. doi: 10.1056/NEJMoa0708638.
    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;42:252–64. doi: 10.1097/CCM.0b013e3182a6384f.
    1. Guerin C. The preventive role of higher PEEP in treating severely hypoxemic ARDS. Minerva Anestesiol. 2011;77:835–45.
    1. Gattinoni L, Pesenti A. The concept of “baby lung”. Intensive Care Med. 2005;31:776–84. doi: 10.1007/s00134-005-2627-z.
    1. Chiumello D, Carlesso E, Cadringher P, Caironi P, Valenza F, Polli F, et al. Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome. Am J Respir Crit Care Med. 2008;178:346–55. doi: 10.1164/rccm.200710-1589OC.
    1. Akoumianaki E, Maggiore SM, Valenza F, Bellani G, Jubran A, Loring SH, et al. The application of esophageal pressure measurement in patients with respiratory failure. Am J Respir Crit Care Med. 2014;189:520–31. doi: 10.1164/rccm.201312-2193CI.
    1. Chiumello D, Marino A, Cressoni M, Mietto C, Berto V, Gallazzi E, et al. Pleural effusion in patients with acute lung injury: a CT scan study. Crit Care Med. 2013;41:935–44. doi: 10.1097/CCM.0b013e318275892c.
    1. Gattinoni L, Caironi P, Cressoni M, Chiumello D, Ranieri VM, Quintel M, et al. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med. 2006;354:1775–86. doi: 10.1056/NEJMoa052052.
    1. Chiumello D, Chidini G, Calderini E, Colombo A, Crimella F, Brioni M. Respiratory mechanics and lung stress/strain in children with acute respiratory distress syndrome. Ann Intensive Care. 2016;6:11. doi: 10.1186/s13613-016-0113-0.
    1. Chiumello D, Cressoni M, Chierichetti M, Tallarini F, Botticelli M, Berto V, et al. Nitrogen washout/washin, helium dilution and computed tomography in the assessment of end expiratory lung volume. Crit Care. 2008;12:R150. doi: 10.1186/cc7139.
    1. Cortes-Puentes GA, Keenan JC, Adams AB, Parker ED, Dries DJ, Marini JJ. Impact of chest wall modifications and lung injury on the correspondence between airway and transpulmonary driving pressures. Crit Care Med. 2015;43:e287–95. doi: 10.1097/CCM.0000000000001036.
    1. Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982;143:29–36. doi: 10.1148/radiology.143.1.7063747.
    1. Dreyfuss D, Saumon G. Ventilator-induced lung injury: lessons from experimental studies. Am J Respir Crit Care Med. 1998;157:294–323. doi: 10.1164/ajrccm.157.1.9604014.
    1. Deans KJ, Minneci PC, Cui X, Banks SM, Natanson C, Eichacker PQ. Mechanical ventilation in ARDS: one size does not fit all. Crit Care Med. 2005;33:1141–3. doi: 10.1097/01.CCM.0000162384.71993.A3.
    1. Hager DN, Krishnan JA, Hayden DL, Brower RG. Tidal volume reduction in patients with acute lung injury when plateau pressures are not high. Am J Respir Crit Care Med. 2005;172:1241–5. doi: 10.1164/rccm.200501-048CP.
    1. Jaswal DS, Leung JM, Sun J, Cui X, Li Y, Kern S, et al. Tidal volume and plateau pressure use for acute lung injury from 2000 to present: a systematic literature review. Crit Care Med. 2014;42:2278–89. doi: 10.1097/CCM.0000000000000504.
    1. Girard TD, Bernard GR. Mechanical ventilation in ARDS: a state-of-the-art review. Chest. 2007;131:921–9. doi: 10.1378/chest.06-1515.
    1. Ibanez J, Raurich JM. Normal values of functional residual capacity in the sitting and supine positions. Intensive Care Med. 1982;8:173–7. doi: 10.1007/BF01725734.
    1. Cinnella G, Grasso S, Raimondo P, D’Antini D, Mirabella L, Rauseo M, et al. Physiological effects of the open lung approach in patients with early, mild, diffuse acute respiratory distress syndrome: an electrical impedance tomography study. Anesthesiology. 2015;123:1113–21. doi: 10.1097/ALN.0000000000000862.
    1. Loring SH, Malhotra A. Driving pressure and respiratory mechanics in ARDS. N Engl J Med. 2015;372:776–7. doi: 10.1056/NEJMe1414218.
    1. Gattinoni L, Pesenti A, Avalli L, Rossi F, Bombino M. Pressure-volume curve of total respiratory system in acute respiratory failure. Computed tomographic scan study. Am Rev Respir Dis. 1987;136:730–6. doi: 10.1164/ajrccm/136.3.730.
    1. Ranieri VM, Brienza N, Santostasi S, Puntillo F, Mascia L, Vitale N, et al. Impairment of lung and chest wall mechanics in patients with acute respiratory distress syndrome: role of abdominal distension. Am J Respir Crit Care Med. 1997;156:1082–91. doi: 10.1164/ajrccm.156.4.97-01052.
    1. Gattinoni L, Pelosi P, Suter PM, Pedoto A, Vercesi P, Lissoni A. Acute respiratory distress syndrome caused by pulmonary and extrapulmonary disease. Different syndromes? Am J Respir Crit Care Med. 1998;158:3–11. doi: 10.1164/ajrccm.158.1.9708031.
    1. Grasso S, Terragni P, Birocco A, Urbino R, Del Sorbo L, Filippini C, et al. ECMO criteria for influenza A (H1N1)-associated ARDS: role of transpulmonary pressure. Intensive Care Med. 2012;38:395–403. doi: 10.1007/s00134-012-2490-7.
    1. Grasso S, Mascia L, Del Turco M, Malacarne P, Giunta F, Brochard L, et al. Effects of recruiting maneuvers in patients with acute respiratory distress syndrome ventilated with protective ventilatory strategy. Anesthesiology. 2002;96:795–802. doi: 10.1097/00000542-200204000-00005.
    1. Mandava S, Kolobow T, Vitale G, Foti G, Aprigliano M, Jones M, et al. Lethal systemic capillary leak syndrome associated with severe ventilator-induced lung injury: an experimental study. Crit Care Med. 2003;31:885–92. doi: 10.1097/01.CCM.0000050294.04869.B8.
    1. Kolobow T, Moretti MP, Fumagalli R, Mascheroni D, Prato P, Chen V, et al. Severe impairment in lung function induced by high peak airway pressure during mechanical ventilation. An experimental study. Am Rev Respir Dis. 1987;135:312–5.
    1. Cressoni M, Chiurazzi C, Gotti M, Amini M, Brioni M, Algieri I, et al. Lung inhomogeneities and time course of ventilator-induced mechanical injuries. Anesthesiology. 2015;123:618–27. doi: 10.1097/ALN.0000000000000727.
    1. Protti A, Andreis DT, Milesi M, Iapichino GE, Monti M, Comini B, et al. Lung anatomy, energy load, and ventilator-induced lung injury. Intensive Care Med Exp. 2015;3:34. doi: 10.1186/s40635-015-0070-1.
    1. American Physiological Society, editor. Handbook of physiology: a critical, comprehensive presentation of physiological knowledge and concepts. Baltimore: Waverly Press; 1986.
    1. Caironi P, Carlesso E, Cressoni M, Chiumello D, Moerer O, Chiurazzi C, et al. Lung recruitability is better estimated according to the Berlin definition of acute respiratory distress syndrome at standard 5 cm H2O rather than higher positive end-expiratory pressure: a retrospective cohort study. Crit Care Med. 2015;43:781–90. doi: 10.1097/CCM.0000000000000770.
    1. Caironi P, Cressoni M, Chiumello D, Ranieri M, Quintel M, Russo SG, et al. Lung opening and closing during ventilation of acute respiratory distress syndrome. Am J Respir Crit Care Med. 2010;181:578–86. doi: 10.1164/rccm.200905-0787OC.
    1. Protti A, Maraffi T, Milesi M, Votta E, Santini A, Pugni P, et al. Role of strain rate in the pathogenesis of ventilator-induced lung edema. Crit. Care Med. 2016. [Epub ahead of print]
    1. Tschumperlin DJ, Oswari J, Margulies AS. Deformation-induced injury of alveolar epithelial cells. Effect of frequency, duration, and amplitude. Am J Respir Crit Care Med. 2000;162:357–62. doi: 10.1164/ajrccm.162.2.9807003.
    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;110:556–65.
    1. Protti A, Votta E, Gattinoni L. Which is the most important strain in the pathogenesis of ventilator-induced lung injury: dynamic or static? Curr Opin Crit Care. 2014;20:33–8. doi: 10.1097/MCC.0000000000000047.
    1. Protti A, Andreis DT, Monti M, Santini A, Sparacino CC, Langer T, et al. Lung stress and strain during mechanical ventilation: any difference between statics and dynamics? Crit Care Med. 2013;41:1046–55. doi: 10.1097/CCM.0b013e31827417a6.

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