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Research ArticleOriginal Research

Transpulmonary Pressure-Guided Lung-Protective Ventilation Improves Pulmonary Mechanics and Oxygenation Among Obese Subjects on Mechanical Ventilation

Daniel D Rowley, Susan R Arrington, Kyle B Enfield, Keith D Lamb, Alexandra Kadl, John P Davis and Danny J Theodore
Respiratory Care July 2021, 66 (7) 1049-1058; DOI: https://doi.org/10.4187/respcare.08686
Daniel D Rowley
Pulmonary Diagnostics & Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, Virginia.
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  • For correspondence: [email protected]
Susan R Arrington
Pulmonary Diagnostics & Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, Virginia.
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Kyle B Enfield
Division of Pulmonary & Critical Care Medicine, University of Virginia Medical Center, Charlottesville, Virginia.
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Keith D Lamb
Pulmonary Diagnostics & Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, Virginia.
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Alexandra Kadl
Division of Pulmonary & Critical Care Medicine, University of Virginia Medical Center, Charlottesville, Virginia.
Department of Pharmacology, University of Virginia, Charlottesville, Virginia.
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John P Davis
Division of Acute Care Surgery, University of Virginia Medical Center, Charlottesville, Virginia.
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Danny J Theodore
Anesthesiology & Critical Care Medicine, University of Virginia Medical Center, Charlottesville, Virginia.
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Abstract

BACKGROUND: Transpulmonary pressure (PL) is used to assess pulmonary mechanics and guide lung-protective mechanical ventilation (LPV). PL is recommended to individualize LPV settings for patients with high pleural pressures and hypoxemia. We aimed to determine whether PL-guided LPV settings, pulmonary mechanics, and oxygenation improve and differ from non-PL-guided LPV among obese patients after 24 h on mechanical ventilation. Secondary outcomes included classification of hypoxemia severity, count of ventilator-free days, ICU length of stay, and overall ICU mortality.

METHODS: This is a retrospective analysis of data. Ventilator settings, pulmonary mechanics, and oxygenation were recorded on the initial day of PL measurement and 24 h later. PL-guided LPV targeted inspiratory PL < 20 cm H2O and expiratory PL of 0–6 cm H2O. Comparisons were made to repeat measurements.

RESULTS: Twenty subjects (13 male) with median age of 49 y, body mass index 47.5 kg/m2, and SOFA score of 8 were included in our analysis. Fourteen subjects received care in a medical ICU. PL measurement occurred 16 h after initiating non-PL-guided LPV. PL-guided LPV resulted in higher median PEEP (14 vs 18 cm H2O, P = .009), expiratory PL (–3 vs 1 cm H2O, P = .02), respiratory system compliance (30.7 vs 44.6 mL/cm H2O, P = .001), and Embedded Image (156 vs 240 mm Hg, P = .002) at 24 h. PL-guided LPV resulted in lower Embedded Image (0.53 vs 0.33, P < .001) and lower PL driving pressure (10 vs 6 cm H2O, P = .001). Tidal volume (420 vs 435 mL, P = .64) and inspiratory PL (7 vs 7 cm H2O, P = .90) were similar. Subjects had a median of 7 ventilator-free days, and median ICU length of stay was 14 d. Three of 20 subjects died within 28 d after ICU admission.

CONCLUSIONS: PL-guided LPV resulted in higher PEEP, lower Embedded Image, improved pulmonary mechanics, and greater oxygenation when compared to non-PL-guided LPV settings in adult obese subjects.

  • mechanical ventilation
  • obesity
  • respiratory mechanics
  • esophageal pressure
  • transpulmonary pressure
  • respiratory support
  • lung-protective ventilation
  • PEEP

Footnotes

  • Correspondence: Daniel D Rowley MSc RRT RRT-ACCS RRT-NPS RPFT FAARC, Pulmonary Diagnostics & Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, VA 22903. E-mail: ddr8a{at}virginia.edu
  • See the Related Editorial on Page 1224

  • Mr Rowley presented a version of this paper as an Editors’ Choice abstract at AARC Congress 2020 LIVE!, held virtually November 18, 2020.

  • Supplementary material related to this paper is available at http://www.rcjournal.com.

  • This work was supported in part by the Pulmonary Diagnostics & Respiratory Therapy Services Department at the University of Virginia Medical Center. Mr Rowley has disclosed relationships with Philips, Ikaria, and Draeger. Mr Lamb discloses a relationship with Fisher & Paykel.

  • Copyright © 2021 by Daedalus Enterprises
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Respiratory Care: 66 (7)
Respiratory Care
Vol. 66, Issue 7
1 Jul 2021
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Transpulmonary Pressure-Guided Lung-Protective Ventilation Improves Pulmonary Mechanics and Oxygenation Among Obese Subjects on Mechanical Ventilation
Daniel D Rowley, Susan R Arrington, Kyle B Enfield, Keith D Lamb, Alexandra Kadl, John P Davis, Danny J Theodore
Respiratory Care Jul 2021, 66 (7) 1049-1058; DOI: 10.4187/respcare.08686

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Transpulmonary Pressure-Guided Lung-Protective Ventilation Improves Pulmonary Mechanics and Oxygenation Among Obese Subjects on Mechanical Ventilation
Daniel D Rowley, Susan R Arrington, Kyle B Enfield, Keith D Lamb, Alexandra Kadl, John P Davis, Danny J Theodore
Respiratory Care Jul 2021, 66 (7) 1049-1058; DOI: 10.4187/respcare.08686
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Keywords

  • mechanical ventilation
  • obesity
  • respiratory mechanics
  • esophageal pressure
  • transpulmonary pressure
  • respiratory support
  • lung-protective ventilation
  • PEEP

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