Capnodynamic monitoring of lung volume and blood flow in response to increased positive end-expiratory pressure in moderate to severe COVID-19 pneumonia: an observational study

Luis Schulz, Antony Stewart, William O'Regan, Peter McCanny, Danielle Austin, Magnus Hallback, Mats Wallin, Anders Aneman, Luis Schulz, Antony Stewart, William O'Regan, Peter McCanny, Danielle Austin, Magnus Hallback, Mats Wallin, Anders Aneman

Abstract

Background: The optimal level of positive end-expiratory pressure (PEEP) during mechanical ventilation for COVID-19 pneumonia remains debated and should ideally be guided by responses in both lung volume and perfusion. Capnodynamic monitoring allows both end-expiratory lung volume ([Formula: see text]) and effective pulmonary blood flow (EPBF) to be determined at the bedside with ongoing ventilation.

Methods: Patients with COVID-19-related moderate to severe respiratory failure underwent capnodynamic monitoring of [Formula: see text] and EPBF during a step increase in PEEP by 50% above the baseline (PEEPlow to PEEPhigh). The primary outcome was a > 20 mm Hg increase in arterial oxygen tension to inspired fraction of oxygen (P/F) ratio to define responders versus non-responders. Secondary outcomes included changes in physiological dead space and correlations with independently determined recruited lung volume and the recruitment-to-inflation ratio at an instantaneous, single breath decrease in PEEP. Mixed factor ANOVA for group mean differences and correlations by Pearson's correlation coefficient are reported including their 95% confidence intervals.

Results: Of 27 patients studied, 15 responders increased the P/F ratio by 55 [24-86] mm Hg compared to 12 non-responders (p < 0.01) as PEEPlow (11 ± 2.7 cm H2O) was increased to PEEPhigh (18 ± 3.0 cm H2O). The [Formula: see text] was 461 [82-839] ml less in responders at PEEPlow (p = 0.02) but not statistically different between groups at PEEPhigh. Responders increased both [Formula: see text] and EPBF at PEEPhigh (r = 0.56 [0.18-0.83], p = 0.03). In contrast, non-responders demonstrated a negative correlation (r = - 0.65 [- 0.12 to - 0.89], p = 0.02) with increased lung volume associated with decreased pulmonary perfusion. Decreased (- 0.06 [- 0.02 to - 0.09] %, p < 0.01) dead space was observed in responders. The change in [Formula: see text] correlated with both the recruited lung volume (r = 0.85 [0.69-0.93], p < 0.01) and the recruitment-to-inflation ratio (r = 0.87 [0.74-0.94], p < 0.01).

Conclusions: In mechanically ventilated patients with moderate to severe COVID-19 respiratory failure, improved oxygenation in response to increased PEEP was associated with increased end-expiratory lung volume and pulmonary perfusion. The change in end-expiratory lung volume was positively correlated with the lung volume recruited and the recruitment-to-inflation ratio. This study demonstrates the feasibility of capnodynamic monitoring to assess physiological responses to PEEP at the bedside to facilitate an individualised setting of PEEP.

Trial registration: NCT05082168 (18th October 2021).

Keywords: COVID-19; Lung perfusion; Lung volume; Mechanical ventilation; Monitoring; Positive end-expiratory pressure.

Conflict of interest statement

MH is a current and MW is a former employee of Maquet Critical Care AB. None of the other authors have any conflicts of interest do declare.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Capnodynamic monitoring of changes in end-expiratory lung volume (∆EELVCO2) and effective pulmonary blood flow (∆EPBF) in patients with (solid dots, black lines) or without (open squares, grey lines) an increase in PaO2/FiO2 by > 20 mm Hg following increased PEEP level (left hand graph). Changes in end-expiratory lung volume (∆EELVCO2) and effective pulmonary blood flow (∆EPBF) are also shown in patients with (stars, black lines) or without (open circles, grey lines) an improvement in Vd/Vt following increased PEEP (right hand graph). Correlations are shown as Pearson’s regression (solid line) with the 95% confidence intervals (dashed lines)
Fig. 2
Fig. 2
Changes in end-expiratory lung volume by capnodynamic monitoring (∆EELVCO2) and the recruited lung volume (∆Volrec) assessed based on the exhaled tidal volume at the rapid reduction from PEEPhigh to PEEPlow as previously described [19]. The correlation is shown as Pearson’s regression (solid line) with the 95% confidence intervals (dashed lines)
Fig. 3
Fig. 3
Changes in end-expiratory lung volume by capnodynamic monitoring (∆EELVCO2) and the recruitment-to-inflation ratio assessed at the rapid reduction from PEEPhigh to PEEPlow as previously described [19]. The correlation is shown as Pearson’s regression (solid line) with the 95% confidence intervals (dashed lines)

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