Mechanical Ventilation Guided by Electrical Impedance Tomography in Children With Acute Lung Injury

OBJECTIVES: To provide proof-of-concept for a protocol applying a strategy of personalized mechanical ventilation in children with acute respiratory distress syndrome. Positive end-expiratory pressure and inspiratory pressure settings were optimized using real-time electrical impedance tomography aiming to maximize lung recruitment while minimizing lung overdistension. DESIGN: Prospective interventional trial. SETTING: Two PICUs. PATIENTS: Eight children with early acute respiratory distress syndrome (< 72 hr). INTERVENTIONS: On 3 consecutive days, electrical impedance tomography-guided positive end-expiratory pressure titration was performed by using regional compliance analysis. The Acute Respiratory Distress Network high/low positive end-expiratory pressure tables were used as patient’s safety guardrails. Driving pressure was maintained constant. Algorithm includes the following: 1) recruitment of atelectasis: increasing positive end-expiratory pressure in steps of 4 mbar; 2) reduction of overdistension: decreasing positive end-expiratory pressure in steps of 2 mbar until electrical impedance tomography shows collapse; and 3) maintaining current positive end-expiratory pressure and check regional compliance every hour. In case of derecruitment start at step 1. MEASUREMENTS AND MAIN RESULTS: Lung areas classified by electrical impedance tomography as collapsed or overdistended were changed on average by –9.1% (95% CI, –13.7 to –4.4; p < 0.001) during titration. Collapse was changed by –9.9% (95% CI, –15.3 to –4.5; p < 0.001), while overdistension did not increase significantly (0.8%; 95% CI, –2.9 to 4.5; p = 0.650). A mean increase of the positive end-expiratory pressure level (1.4 mbar; 95% CI, 0.6–2.2; p = 0.008) occurred after titration. Global respiratory system compliance and gas exchange improved (global respiratory system compliance: 1.3 mL/mbar, 95% CI [–0.3 to 3.0], p = 0.026; Pao(2): 17.6 mm Hg, 95% CI [7.8–27.5], p = 0.0039; and Pao(2)/Fio(2) ratio: 55.2 mm Hg, 95% CI [27.3–83.2], p < 0.001, all values are change in pre vs post). CONCLUSIONS: Electrical impedance tomography-guided positive end-expiratory pressure titration reduced regional lung collapse without significant increase of overdistension, while improving global compliance and gas exchange in children with acute respiratory distress syndrome.