Changes in shunt, ventilation/perfusion mismatch, and lung aeration with PEEP in patients with ARDS: a prospective single-arm interventional study
Dan Stieper Karbing, Mauro Panigada, Nicola Bottino, Elena Spinelli, Alessandro Protti, Stephen Edward Rees, Luciano Gattinoni, Dan Stieper Karbing, Mauro Panigada, Nicola Bottino, Elena Spinelli, Alessandro Protti, Stephen Edward Rees, Luciano Gattinoni
Abstract
Background: Several studies have found only a weak to moderate correlation between oxygenation and lung aeration in response to changes in PEEP. This study aimed to investigate the association between changes in shunt, low and high ventilation/perfusion (V/Q) mismatch, and computed tomography-measured lung aeration following an increase in PEEP in patients with ARDS.
Methods: In this preliminary study, 12 ARDS patients were subjected to recruitment maneuvers followed by setting PEEP at 5 and then either 15 or 20 cmH2O. Lung aeration was measured by computed tomography. Values of pulmonary shunt and low and high V/Q mismatch were calculated by a model-based method from measurements of oxygenation, ventilation, and metabolism taken at different inspired oxygen levels and an arterial blood gas sample.
Results: Increasing PEEP resulted in reduced values of pulmonary shunt and the percentage of non-aerated tissue, and an increased percentage of normally aerated tissue (p < 0.05). Changes in shunt and normally aerated tissue were significantly correlated (r = - 0.665, p = 0.018). Three distinct responses to increase in PEEP were observed in values of shunt and V/Q mismatch: a beneficial response in seven patients, where shunt decreased without increasing high V/Q; a detrimental response in four patients where both shunt and high V/Q increased; and a detrimental response in a patient with reduced shunt but increased high V/Q mismatch. Non-aerated tissue decreased with increased PEEP in all patients, and hyperinflated tissue increased only in patients with a detrimental response in shunt and V/Q mismatch.
Conclusions: The results show that improved lung aeration following an increase in PEEP is not always consistent with reduced shunt and V/Q mismatch. Poorly matched redistribution of ventilation and perfusion, between dependent and non-dependent regions of the lung, may explain why patients showed detrimental changes in shunt and V/Q mismatch on increase in PEEP, despite improved aeration.
Trial registration: ClinicalTrails.gov, NCT04067154. Retrospectively registered on August 26, 2019.
Keywords: ARDS; CT; Lung aeration; PEEP; Shunt; Ventilation/perfusion mismatch.
Conflict of interest statement
DSK and SER’s institution has received funding from Mermaid Care A/S. DSK and SER have performed consultancy work for Mermaid Care A/S. DSK and SER are minor shareholders in Mermaid Care A/S, and SER is an unpaid board member of the company. MP, NB, ES, AP, and LG have no further potential conflicts of interest.
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References
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