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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 
(156 vs 240 mm Hg, P = .002) at 24 h. PL-guided LPV resulted in lower 
(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 
, 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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