Positive end-expiratory pressure induced changes in airway driving pressure in mechanically ventilated COVID-19 Acute Respiratory Distress Syndrome patients

BACKGROUND: The profile of changes in airway driving pressure (dP(aw)) induced by positive-end expiratory pressure (PEEP) might aid for individualized protective ventilation. Our aim was to describe the dP(aw) versus PEEP curves behavior in ARDS from COVID-19 patients. METHODS: Patients admitted in three hospitals were ventilated with fraction of inspired oxygen (FiO(2)) and PEEP initially adjusted by oxygenation-based table. Thereafter, PEEP was reduced from 20 until 6 cmH(2)O while dP(aw) was stepwise recorded and the lowest PEEP that minimized dP(aw) (PEEPmin_dP(aw)) was assessed. Each dP(aw) vs PEEP curve was classified as J-shaped, inverted-J-shaped, or U-shaped according to the difference between the minimum dP(aw) and the dP(aw) at the lowest and highest PEEP. In one hospital, hyperdistention and collapse at each PEEP were assessed by electrical impedance tomography (EIT). RESULTS: 184 patients (41 including EIT) were studied. 126 patients (68%) exhibited a J-shaped dP(aw) vs PEEP profile (PEEPmin_dP(aw) of 7.5 ± 1.9 cmH(2)O). 40 patients (22%) presented a U (PEEPmin_dP(aw) of 12.2 ± 2.6 cmH(2)O) and 18 (10%) an inverted-J profile (PEEPmin_dP(aw) of 14,6 ± 2.3 cmH(2)O). Patients with inverted-J profiles had significant higher body mass index (BMI) and lower baseline partial pressure of arterial oxygen/FiO(2) ratio. PEEPmin_dP(aw) was associated with lower fractions of both alveolar collapse and hyperinflation. CONCLUSIONS: A PEEP adjustment procedure based on PEEP-induced changes in dP(aw) is feasible and may aid in individualized PEEP for protective ventilation. The PEEP required to minimize driving pressure was influenced by BMI and was low in the majority of patients.