Electric impedance tomography-guided PEEP titration reduces mechanical power in ARDS: a randomized crossover pilot trial

Jose Victor Jimenez; Elizabeth Munroe; Andrew J Weirauch; Kelly Fiorino; Christopher A Culter; Kristine Nelson; Wassim W Labaki; Philip J Choi; Ivan Co; Theodore J Standiford; Hallie C Prescott; Robert C Hyzy

doi:10.1186/s13054-023-04315-x

Electric impedance tomography-guided PEEP titration reduces mechanical power in ARDS: a randomized crossover pilot trial

Crit Care. 2023 Jan 17;27(1):21. doi: 10.1186/s13054-023-04315-x.

Authors

Affiliations

¹ Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr. Floor 3 Reception C, Ann Arbor, MI, 48109, USA.
² UH/CVC Department of Respiratory Care, University of Michigan, Ann Arbor, MI, USA.
³ VA Center for Clinical Management Research, Ann Arbor, MI, USA.
⁴ Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr. Floor 3 Reception C, Ann Arbor, MI, 48109, USA. rhyzy@med.umich.edu.

Abstract

Background: In patients with acute respiratory distress syndrome undergoing mechanical ventilation, positive end-expiratory pressure (PEEP) can lead to recruitment or overdistension. Current strategies utilized for PEEP titration do not permit the distinction. Electric impedance tomography (EIT) detects and quantifies the presence of both collapse and overdistension. We investigated whether using EIT-guided PEEP titration leads to decreased mechanical power compared to high-PEEP/FiO2 tables.

Methods: A single-center, randomized crossover pilot trial comparing EIT-guided PEEP selection versus PEEP selection using the High-PEEP/FiO₂ table in patients with moderate-severe acute respiratory distress syndrome. The primary outcome was the change in mechanical power after each PEEP selection strategy. Secondary outcomes included changes in the 4 × driving pressure + respiratory rate (4 ΔP, + RR index) index, driving pressure, plateau pressure, PaO₂/FiO₂ ratio, and static compliance.

Results: EIT was consistently associated with a decrease in mechanical power compared to PEEP/FiO₂ tables (mean difference - 4.36 J/min, 95% CI - 6.7, - 1.95, p = 0.002) and led to lower values in the 4ΔP + RR index (- 11.42 J/min, 95% CI - 19.01, - 3.82, p = 0.007) mainly driven by a decrease in the elastic-dynamic power (- 1.61 J/min, - 2.99, - 0.22, p = 0.027). The elastic-static and resistive powers were unchanged. Similarly, EIT led to a statistically significant change in set PEEP (- 2 cmH₂O, p = 0.046), driving pressure, (- 2.92 cmH2O, p = 0.003), peak pressure (- 6.25 cmH₂O, p = 0.003), plateau pressure (- 4.53 cmH₂O, p = 0.006), and static respiratory system compliance (+ 7.93 ml/cmH₂O, p = 0.008).

Conclusions: In patients with moderate-severe acute respiratory distress syndrome, EIT-guided PEEP titration reduces mechanical power mainly through a reduction in elastic-dynamic power. Trial registration This trial was prospectively registered on Clinicaltrials.gov (NCT03793842) on January 4th, 2019.

Keywords: Acute lung injury; Electrical impedance tomography; Mechanical ventilators; Respiratory distress syndrome; Ventilator-induced lung injury.

Publication types

Randomized Controlled Trial

MeSH terms

Electric Impedance
Humans
Pilot Projects
Positive-Pressure Respiration / methods
Respiratory Distress Syndrome* / therapy
Tomography / methods

Associated data

ClinicalTrials.gov/NCT03793842