Transoesophageal Ultrasound Assessment of Lung Aeration in Patients With Acute Respiratory Distress Syndrome

Introduction: The effect of positive end-expiratory pressure (PEEP) depends closely on the potential for lung recruitment. Bedside assessment of lung recruitability is crucial for personalized lung-protective mechanical ventilation in acute respiratory distress syndrome (ARDS) patients. Methods: We developed a transoesophageal lung ultrasound (TE-LUS) method in which a quantitative (computer-assisted) grayscale determination served as a guide to PEEP-induced lung recruitment. The method is based on the following hypothesis: when the PEEP increases, inflation of the recruited alveoli leads to significant changes in the air/water ratio. Normally ventilated areas are hypoechoic because the ultrasound waves are weakly reflected while poorly aerated areas or non-aerated areas are hyperechoic. We calculated the TE-LUS re-aeration score (RAS) as the ratio of the mean gray scale level at low PEEP to that value at high PEEP for the lower and upper lobes. A RAS > 1 indicated an increase in ventilated area. We used this new method to detect changes in ventilation in patients with a low (<0.5) vs. high (≥0.5) recruitment-to-inflation (R/I) ratio (i.e., the ratio between the recruited lung compliance and the respiratory system compliance at low PEEP). Results: We included 30 patients with moderate-to-severe ARDS. In patients with a high R/I ratio, the TE-LUS RAS was significantly higher in the lower lobes than in the upper lobes (1.20 [1.12–1.63] vs. 1.05 [0.89–1.38]; p = 0.05). Likewise, the TE-LUS RAS in the lower lobes was significantly higher in the high R/I group than in the low R/I group (1.20 [1.12–1.63] vs. 1.07 [1.00–1.20]; p = 0.04). Conclusion: The increase in PEEP induces a substantial gain in the ventilation detected by TE-LUS of poorly or non-aerated lower lobes (dependent lung regions), especially in patients with a high R/I ratio.