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Research ArticleOriginal Research

Transpulmonary Pressure and Gas Exchange During Decremental PEEP Titration in Pulmonary ARDS Patients

Pablo O Rodriguez, Ignacio Bonelli, Mariano Setten, Shiry Attie, Matias Madorno, Luis P Maskin and Ricardo Valentini
Respiratory Care May 2013, 58 (5) 754-763; DOI: https://doi.org/10.4187/respcare.01977
Pablo O Rodriguez
Intensive Care Unit, CEMIC (Centro de Educación Médica e Investigaciones Clínicas), Buenos Aires, Argentina.
Instituto Universitario CEMIC, Buenos Aires, Argentina.
Pulmonary Medicine Section, Department of Medicine, CEMIC, Buenos Aires, Argentina.
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  • For correspondence: [email protected]
Ignacio Bonelli
Intensive Care Unit, CEMIC (Centro de Educación Médica e Investigaciones Clínicas), Buenos Aires, Argentina.
Instituto Universitario CEMIC, Buenos Aires, Argentina.
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Mariano Setten
Intensive Care Unit, CEMIC (Centro de Educación Médica e Investigaciones Clínicas), Buenos Aires, Argentina.
Department of Physiotherapy, CEMIC, Buenos Aires, Argentina.
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Shiry Attie
Intensive Care Unit, CEMIC (Centro de Educación Médica e Investigaciones Clínicas), Buenos Aires, Argentina.
Instituto Universitario CEMIC, Buenos Aires, Argentina.
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Matias Madorno
Instituto Tecnológico de Buenos Aires, Buenos Aires, Argentina.
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Luis P Maskin
Intensive Care Unit, CEMIC (Centro de Educación Médica e Investigaciones Clínicas), Buenos Aires, Argentina.
Instituto Universitario CEMIC, Buenos Aires, Argentina.
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Ricardo Valentini
Intensive Care Unit, CEMIC (Centro de Educación Médica e Investigaciones Clínicas), Buenos Aires, Argentina.
Instituto Universitario CEMIC, Buenos Aires, Argentina.
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Abstract

BACKGROUND: Selection of the PEEP associated with the best compliance of the respiratory system during decremental PEEP titration can be used for the treatment of patients suffering from ARDS. We describe changes in transpulmonary pressure (Ptp) and gas exchange during a decremental PEEP titration maneuver in subjects with pulmonary ARDS.

METHODS: Eleven subjects with early ARDS were included. After a recruitment maneuver they were ventilated in volume-controlled ventilation and PEEP was decreased from 30 to 0 cm H2O by steps of 3 cm H2O. Static airway pressure (Paw), esophageal pressure (Pes), Ptp (Paw – Pes), the ratio of dead space to tidal volume (VD/VT), and PaO2 were recorded at each step.

RESULTS: A linear correlation was found between Paw and Ptp. Expiratory Ptp became negative in all subjects when PEEP decreased below 8.9 ± 5.2 cm H2O. VD/VT was 0.67 ± 0.06 with 30 cm H2O of PEEP, and decreased 15.4 ± 8.5% during the maneuver, when PEEP and expiratory Ptp were 10.6 ± 4.1 cm H2O and 1.2 ± 2.8 cm H2O, respectively. VD/VT was significantly higher during ventilation at high (> 18 cm H2O), compared to low, inspiratory Ptp values (P < .001). PaO2 decreased when expiratory Ptp became negative (P < .001).

CONCLUSIONS: During decremental PEEP titration we sequentially observed high inspiratory Ptp that stressed lung tissue and increased VD/VT, and negative Ptp, indicating high risk of alveolar collapse, explaining worse oxygenation. PEEP selection based on Ptp and VD/VT in ARDS may help to avoid these situations.

  • ARDS
  • respiratory dead space
  • mechanical ventilation
  • ventilator induced lung injury
  • PEEP
  • acute lung injury

Footnotes

  • Correspondence: Pablo O Rodriguez MD, Servicio de Terapia Intensiva, CEMIC, Avenida Las Heras 2900, C1425ASS, Buenos Aires, Argentina. E-mail: prodriguez{at}cemic.edu.ar.
  • Dr Rodriguez presented a version of this paper at the annual congress of the Sociedad Argentina de Terapia Intensiva, held September 30 through October 3, 2010, in Mar del Plata, Argentina, and at the European Society of Intensive Care Medicine Annual Congress held October 1–5, 2011, in Berlin, Germany.

  • The authors have disclosed no conflicts of interest.

  • See the Related Editorial on Page 886

  • Copyright © 2013 by Daedalus Enterprises
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Respiratory Care: 58 (5)
Respiratory Care
Vol. 58, Issue 5
1 May 2013
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Transpulmonary Pressure and Gas Exchange During Decremental PEEP Titration in Pulmonary ARDS Patients
Pablo O Rodriguez, Ignacio Bonelli, Mariano Setten, Shiry Attie, Matias Madorno, Luis P Maskin, Ricardo Valentini
Respiratory Care May 2013, 58 (5) 754-763; DOI: 10.4187/respcare.01977

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Transpulmonary Pressure and Gas Exchange During Decremental PEEP Titration in Pulmonary ARDS Patients
Pablo O Rodriguez, Ignacio Bonelli, Mariano Setten, Shiry Attie, Matias Madorno, Luis P Maskin, Ricardo Valentini
Respiratory Care May 2013, 58 (5) 754-763; DOI: 10.4187/respcare.01977
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Keywords

  • ARDS
  • respiratory dead space
  • mechanical ventilation
  • ventilator induced lung injury
  • PEEP
  • acute lung injury

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