Influence of overdistension/recruitment induced by high positive end-expiratory pressure on ventilation-perfusion matching assessed by electrical impedance tomography with saline bolus

Huaiwu He, Yi Chi, Yun Long, Siyi Yuan, Inéz Frerichs, Knut Möller, Feng Fu, Zhanqi Zhao, Huaiwu He, Yi Chi, Yun Long, Siyi Yuan, Inéz Frerichs, Knut Möller, Feng Fu, Zhanqi Zhao

Abstract

Background: High positive end-expiratory pressures (PEEP) may induce overdistension/recruitment and affect ventilation-perfusion matching (VQMatch) in mechanically ventilated patients. This study aimed to investigate the association between PEEP-induced lung overdistension/recruitment and VQMatch by electrical impedance tomography (EIT).

Methods: The study was conducted prospectively on 30 adult mechanically ventilated patients: 18/30 with ARDS and 12/30 with high risk for ARDS. EIT measurements were performed at zero end-expiratory pressures (ZEEP) and subsequently at high (12-15 cmH2O) PEEP. The number of overdistended pixels over the number of recruited pixels (O/R ratio) was calculated, and the patients were divided into low O/R (O/R ratio < 15%) and high O/R groups (O/R ratio ≥ 15%). The global inhomogeneity (GI) index was calculated to evaluate the ventilation distribution. Lung perfusion image was calculated from the EIT impedance-time curves caused by 10 ml 10% NaCl injection during a respiratory pause (> 8 s). DeadSpace%, Shunt%, and VQMatch% were calculated based on lung EIT perfusion and ventilation images.

Results: Increasing PEEP resulted in recruitment mainly in dorsal regions and overdistension mainly in ventral regions. ΔVQMatch% (VQMatch% at high PEEP minus that at ZEEP) was significantly correlated with recruited pixels (r = 0.468, P = 0.009), overdistended pixels (r = - 0.666, P < 0.001), O/R ratio (r = - 0.686, P < 0.001), and ΔSpO2 (r = 0.440, P = 0.015). Patients in the low O/R ratio group (14/30) had significantly higher Shunt% and lower VQMatch% than those in the high O/R ratio group (16/30) at ZEEP but not at high PEEP. Comparable DeadSpace% was found in both groups. A high PEEP caused a significant improvement of VQMatch%, DeadSpace%, Shunt%, and GI in the low O/R ratio group, but not in the high O/R ratio group. Using O/R ratio of 15% resulted in a sensitivity of 81% and a specificity of 100% for an increase of VQMatch% > 20% in response to high PEEP.

Conclusions: Change of ventilation-perfusion matching was associated with regional overdistention and recruitment induced by PEEP. A low O/R ratio induced by high PEEP might indicate a more homogeneous ventilation and improvement of VQMatch.

Trial registration: ClinicalTrials.gov, NCT04081155 . Registered on 9 September 2019-retrospectively registered.

Keywords: Dead space; Electrical impedance tomography; Lung perfusion; Overdistension; Recruitment; Shunt; Ventilation distribution; Ventilation–perfusion matching.

Conflict of interest statement

Zhanqi Zhao receives a consulting fee from Dräger Medical. Inéz Frerichs reports funding from the European Union’s Framework Programme for Research and Innovation Horizon 2020 (WELMO, Grant No. 825572) and reimbursement of speaking fees, congress, and travel costs by Dräger Medical. The other authors declare no conflict of interest.

Figures

Fig. 1
Fig. 1
Illustration of the data analysis method of regional recruitment, overdistension, and V-Q matching in one study patient. Top: tidal variation images at ZEEP (left), PEEP (middle), and the corresponding difference image (right). In the tidal variation images, regions with low ventilation are marked in dark blue and highly ventilated regions in light blue to white. Collapsed or overdistended regions are comprised in the low/non-ventilated dark blue or black areas. In the difference image, ventilation gain and loss at PEEP compared to ZEEP are marked in blue and orange, respectively. Middle: perfusion images at ZEEP (left) and PEEP (middle). Highly perfused regions are marked in red. Colorbars in arbitrary units. Recruited and overdistended regions were defined based on ventilation difference image (right). Bottom: regional V-Q matching images at ZEEP (left) and PEEP (right)
Fig. 2
Fig. 2
Comparisons of VQMatch%, Shunt%, and DeadSpace% between low O/R and high O/R groups at ZEEP (left) and PEEP (right). *P < 0.05 compared to low O/R
Fig. 3
Fig. 3
ΔVQMatch%, ΔShunt%, ΔDeadSpace%, and ΔGI induced by PEEP in the low O/R and high O/R groups. Δ = high PEEP – ZEEP. *P < 0.05 compared to low O/R
Fig. 4
Fig. 4
The areas under the receiver operating characteristic curves (AUC) of O/R ratio, total recruited pixels, and total overdistended pixels used for prediction of an increase of VQMatch% > 20% in the incremental PEEP trial. * < 0.05, vs. AUC of total recruited pixels

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