Mechanical Ventilation Guided by Electrical Impedance Tomography in Children With Acute Lung Injury

Isabel Rosemeier, Karl Reiter, Viola Obermeier, Gerhard K Wolf, Isabel Rosemeier, Karl Reiter, Viola Obermeier, Gerhard K Wolf

Abstract

Objectives: To provide proof-of-concept for a protocol applying a strategy of personalized mechanical ventilation in children with acute respiratory distress syndrome. Positive end-expiratory pressure and inspiratory pressure settings were optimized using real-time electrical impedance tomography aiming to maximize lung recruitment while minimizing lung overdistension.

Design: Prospective interventional trial.

Setting: Two PICUs.

Patients: Eight children with early acute respiratory distress syndrome (< 72 hr).

Interventions: On 3 consecutive days, electrical impedance tomography-guided positive end-expiratory pressure titration was performed by using regional compliance analysis. The Acute Respiratory Distress Network high/low positive end-expiratory pressure tables were used as patient's safety guardrails. Driving pressure was maintained constant. Algorithm includes the following: 1) recruitment of atelectasis: increasing positive end-expiratory pressure in steps of 4 mbar; 2) reduction of overdistension: decreasing positive end-expiratory pressure in steps of 2 mbar until electrical impedance tomography shows collapse; and 3) maintaining current positive end-expiratory pressure and check regional compliance every hour. In case of derecruitment start at step 1.

Measurements and main results: Lung areas classified by electrical impedance tomography as collapsed or overdistended were changed on average by -9.1% (95% CI, -13.7 to -4.4; p < 0.001) during titration. Collapse was changed by -9.9% (95% CI, -15.3 to -4.5; p < 0.001), while overdistension did not increase significantly (0.8%; 95% CI, -2.9 to 4.5; p = 0.650). A mean increase of the positive end-expiratory pressure level (1.4 mbar; 95% CI, 0.6-2.2; p = 0.008) occurred after titration. Global respiratory system compliance and gas exchange improved (global respiratory system compliance: 1.3 mL/mbar, 95% CI [-0.3 to 3.0], p = 0.026; Pao2: 17.6 mm Hg, 95% CI [7.8-27.5], p = 0.0039; and Pao2/Fio2 ratio: 55.2 mm Hg, 95% CI [27.3-83.2], p < 0.001, all values are change in pre vs post).

Conclusions: Electrical impedance tomography-guided positive end-expiratory pressure titration reduced regional lung collapse without significant increase of overdistension, while improving global compliance and gas exchange in children with acute respiratory distress syndrome.

Keywords: electrical impedance tomography; mechanical ventilation; pediatric acute respiratory distress syndrome; personalized ventilation.

Conflict of interest statement

The authors have disclosed that they do not have any potential conflicts of interest.

Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.

Figures

Figure 1.
Figure 1.
Display options “WIN/LOSS” (all pixels with compliance win and all pixels with compliance loss [A, B, C]) and “OD/CL” (lung overdistension and collapse [D, E, F]) at three different positive end-expiratory pressure (PEEP) levels during PEEP titration. PEEP 12 would be chosen as optimal PEEP level.
Figure 2.
Figure 2.
Overdistension and collapse (OD/CL) (B) and positive end-expiratory pressure (PEEP) levels (C) before and after the PEEP titration. OD and CL (A), heart rate (HR) (D) and mean arterial pressure (MAP) (E) at the start, the maximum PEEP level and the end of titration. bpm = beats/min.

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Source: PubMed

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