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Meeting ReportEditors' Choice

Transpulmonary Pressure-Guided Lung Protective Ventilation Improves Pulmonary Mechanics and Oxygenation in Adult Obese Patients

Daniel D Rowley, Susan R Arrington, Thomas P Malinowski, Keith D Lamb, Danny J Theodore, John P Davis and Alexandra Kadl
Respiratory Care October 2020, 65 (Suppl 10) 3441746;
Daniel D Rowley
Pulmonary Diagnostics & Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, Virginia, United States
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Susan R Arrington
Pulmonary Diagnostics & Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, Virginia, United States
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Thomas P Malinowski
Pulmonary Diagnostics & Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, Virginia, United States
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Keith D Lamb
Pulmonary Diagnostics & Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, Virginia, United States
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Danny J Theodore
Anesthesiology & Critical Care Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, United States
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John P Davis
Acute Care Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, United States
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Alexandra Kadl
Pulmonary & Critical Care Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, United States
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Abstract

Background: Transpulmonary pressure (PL) manometry is used to assess pulmonary mechanics and guide lung protective mechanical ventilation (LPV). PL manometry is recommended to individualize LPV settings for patients with increased chest wall elastance and hypoxemia. Our primary aim was to determine if non-PL guided LPV settings, pulmonary mechanics, and oxygenation differ 1-day after receiving PL guided LPV among obese mechanically ventilated (MV) patients. Secondary endpoints: Ventilator-free days (VFD), ICU length of stay (LOS), and overall ICU mortality..

Methods: This was an IRB approved retrospective analysis of prospectively collected quality improvement data from MV adult obese patients. All patients were MV for a period prior to placement of an esophageal balloon catheter. Ventilator settings, pulmonary mechanics, and oxygenation were recorded on the initial day of PL measurement (D1, non-PL guided LPV). PL guided LPV targeted Inspiratory PL < 20 cm H2O and expiratory PL 0-6 cm H2O. PEEP was adjusted according to a FIO2/PL Table. Comparisons were made to repeat measurements done on day 2 (D2, PL guided LPV). Hypoxemia severity was also compared. Data reported as n (%) and median (IQR). Alpha set at .05.

Results: 19 patients (63% male) with median age 49 (40-65) y, BMI 46.3 (36.6-55.9) kg/m2, and SOFA score 8 (6-11) were included in our sample. 13 (68%) patients received care in the medical ICU and 6 (32%) in our surgical/trauma ICU. PL measurement occurred 16 (9-21) h after initiating non-PL guided LPV in an effort to optimize ventilator settings. PL guided LPV resulted in higher PEEP [14 (14-20) vs 18 (17-25)], P <.01), Expiratory PL [-3 (-5 to -1) vs 1 (0 to 3), P <.01], Crs [30 (26-42) vs 43 (37-51), P <.01], and PaO2/FIO2 [165 (106-193) vs 246 (204-286), P <.01] at D2. PL guided LPV resulted in lower FIO2 [.60 (.40-.90) vs .30 (.30-.40), P <.01)] and lower Driving Pressure [14 (10-15) vs 10 (8-11), P =.01]. VT [420 (360-457)] vs 435 (363-463) mL, P =.64) and Inspiratory PL [7 (2-11) vs 8 (5-10), P =.55) were similar. Hypoxemia was lower after PL guided ventilator setting adjustment (Table). VFD ranged from 2-28 [8 (6-12)] d and ICU LOS was 17 (11-27) d. ICU mortality was 11% (n=2/19).

Conclusions: PL guided LPV results in higher PEEP, lower FIO2, improved pulmonary mechanics, and greater oxygenation when compared to non-PL guided LPV MV settings in adult obese patients. Future studies should evaluate early PL guided LPV among obese pts and the effect on VFD, ICU LOS, and ICU mortality.

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Footnotes

  • Commercial Relationships: Daniel D Rowley: Consultant for Philips and Ikaria; Received research equipment support from Draeger. Thomas P Malinowski has received sponsored research equipment from Draeger. Keith Lamb: Consultant for Fisher & Paykel

  • Copyright © 2020 by Daedalus Enterprises
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Respiratory Care
Vol. 65, Issue Suppl 10
1 Oct 2020
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Transpulmonary Pressure-Guided Lung Protective Ventilation Improves Pulmonary Mechanics and Oxygenation in Adult Obese Patients
Daniel D Rowley, Susan R Arrington, Thomas P Malinowski, Keith D Lamb, Danny J Theodore, John P Davis, Alexandra Kadl
Respiratory Care Oct 2020, 65 (Suppl 10) 3441746;

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Transpulmonary Pressure-Guided Lung Protective Ventilation Improves Pulmonary Mechanics and Oxygenation in Adult Obese Patients
Daniel D Rowley, Susan R Arrington, Thomas P Malinowski, Keith D Lamb, Danny J Theodore, John P Davis, Alexandra Kadl
Respiratory Care Oct 2020, 65 (Suppl 10) 3441746;
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