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Positive end-expiratory pressure in COVID-19 acute respiratory distress syndrome: the heterogeneous effects
BACKGROUND: We hypothesized that as CARDS may present different pathophysiological features than classic ARDS, the application of high levels of end-expiratory pressure is questionable. Our first aim was to investigate the effects of 5–15 cmH(2)O of PEEP on partitioned respiratory mechanics, gas exc...
Autores principales: | , , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
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BioMed Central
2021
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8674862/ https://www.ncbi.nlm.nih.gov/pubmed/34915911 http://dx.doi.org/10.1186/s13054-021-03839-4 |
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author | Chiumello, Davide Bonifazi, Matteo Pozzi, Tommaso Formenti, Paolo Papa, Giuseppe Francesco Sferrazza Zuanetti, Gabriele Coppola, Silvia |
author_facet | Chiumello, Davide Bonifazi, Matteo Pozzi, Tommaso Formenti, Paolo Papa, Giuseppe Francesco Sferrazza Zuanetti, Gabriele Coppola, Silvia |
author_sort | Chiumello, Davide |
collection | PubMed |
description | BACKGROUND: We hypothesized that as CARDS may present different pathophysiological features than classic ARDS, the application of high levels of end-expiratory pressure is questionable. Our first aim was to investigate the effects of 5–15 cmH(2)O of PEEP on partitioned respiratory mechanics, gas exchange and dead space; secondly, we investigated whether respiratory system compliance and severity of hypoxemia could affect the response to PEEP on partitioned respiratory mechanics, gas exchange and dead space, dividing the population according to the median value of respiratory system compliance and oxygenation. Thirdly, we explored the effects of an additional PEEP selected according to the Empirical PEEP-FiO(2) table of the EPVent-2 study on partitioned respiratory mechanics and gas exchange in a subgroup of patients. METHODS: Sixty-one paralyzed mechanically ventilated patients with a confirmed diagnosis of SARS-CoV-2 were enrolled (age 60 [54–67] years, PaO(2)/FiO(2) 113 [79–158] mmHg and PEEP 10 [10–10] cmH(2)O). Keeping constant tidal volume, respiratory rate and oxygen fraction, two PEEP levels (5 and 15 cmH(2)O) were selected. In a subgroup of patients an additional PEEP level was applied according to an Empirical PEEP-FiO(2) table (empirical PEEP). At each PEEP level gas exchange, partitioned lung mechanics and hemodynamic were collected. RESULTS: At 15 cmH(2)O of PEEP the lung elastance, lung stress and mechanical power were higher compared to 5 cmH(2)O. The PaO(2)/FiO(2), arterial carbon dioxide and ventilatory ratio increased at 15 cmH(2)O of PEEP. The arterial–venous oxygen difference and central venous saturation were higher at 15 cmH(2)O of PEEP. Both the mechanics and gas exchange variables significantly increased although with high heterogeneity. By increasing the PEEP from 5 to 15 cmH(2)O, the changes in partitioned respiratory mechanics and mechanical power were not related to hypoxemia or respiratory compliance. The empirical PEEP was 18 ± 1 cmH(2)O. The empirical PEEP significantly increased the PaO(2)/FiO(2) but also driving pressure, lung elastance, lung stress and mechanical power compared to 15 cmH(2)O of PEEP. CONCLUSIONS: In COVID-19 ARDS during the early phase the effects of raising PEEP are highly variable and cannot easily be predicted by respiratory system characteristics, because of the heterogeneity of the disease. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13054-021-03839-4. |
format | Online Article Text |
id | pubmed-8674862 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2021 |
publisher | BioMed Central |
record_format | MEDLINE/PubMed |
spelling | pubmed-86748622021-12-16 Positive end-expiratory pressure in COVID-19 acute respiratory distress syndrome: the heterogeneous effects Chiumello, Davide Bonifazi, Matteo Pozzi, Tommaso Formenti, Paolo Papa, Giuseppe Francesco Sferrazza Zuanetti, Gabriele Coppola, Silvia Crit Care Research BACKGROUND: We hypothesized that as CARDS may present different pathophysiological features than classic ARDS, the application of high levels of end-expiratory pressure is questionable. Our first aim was to investigate the effects of 5–15 cmH(2)O of PEEP on partitioned respiratory mechanics, gas exchange and dead space; secondly, we investigated whether respiratory system compliance and severity of hypoxemia could affect the response to PEEP on partitioned respiratory mechanics, gas exchange and dead space, dividing the population according to the median value of respiratory system compliance and oxygenation. Thirdly, we explored the effects of an additional PEEP selected according to the Empirical PEEP-FiO(2) table of the EPVent-2 study on partitioned respiratory mechanics and gas exchange in a subgroup of patients. METHODS: Sixty-one paralyzed mechanically ventilated patients with a confirmed diagnosis of SARS-CoV-2 were enrolled (age 60 [54–67] years, PaO(2)/FiO(2) 113 [79–158] mmHg and PEEP 10 [10–10] cmH(2)O). Keeping constant tidal volume, respiratory rate and oxygen fraction, two PEEP levels (5 and 15 cmH(2)O) were selected. In a subgroup of patients an additional PEEP level was applied according to an Empirical PEEP-FiO(2) table (empirical PEEP). At each PEEP level gas exchange, partitioned lung mechanics and hemodynamic were collected. RESULTS: At 15 cmH(2)O of PEEP the lung elastance, lung stress and mechanical power were higher compared to 5 cmH(2)O. The PaO(2)/FiO(2), arterial carbon dioxide and ventilatory ratio increased at 15 cmH(2)O of PEEP. The arterial–venous oxygen difference and central venous saturation were higher at 15 cmH(2)O of PEEP. Both the mechanics and gas exchange variables significantly increased although with high heterogeneity. By increasing the PEEP from 5 to 15 cmH(2)O, the changes in partitioned respiratory mechanics and mechanical power were not related to hypoxemia or respiratory compliance. The empirical PEEP was 18 ± 1 cmH(2)O. The empirical PEEP significantly increased the PaO(2)/FiO(2) but also driving pressure, lung elastance, lung stress and mechanical power compared to 15 cmH(2)O of PEEP. CONCLUSIONS: In COVID-19 ARDS during the early phase the effects of raising PEEP are highly variable and cannot easily be predicted by respiratory system characteristics, because of the heterogeneity of the disease. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13054-021-03839-4. BioMed Central 2021-12-16 /pmc/articles/PMC8674862/ /pubmed/34915911 http://dx.doi.org/10.1186/s13054-021-03839-4 Text en © The Author(s) 2021 https://creativecommons.org/licenses/by/4.0/Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ (https://creativecommons.org/licenses/by/4.0/) . The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/ (https://creativecommons.org/publicdomain/zero/1.0/) ) applies to the data made available in this article, unless otherwise stated in a credit line to the data. |
spellingShingle | Research Chiumello, Davide Bonifazi, Matteo Pozzi, Tommaso Formenti, Paolo Papa, Giuseppe Francesco Sferrazza Zuanetti, Gabriele Coppola, Silvia Positive end-expiratory pressure in COVID-19 acute respiratory distress syndrome: the heterogeneous effects |
title | Positive end-expiratory pressure in COVID-19 acute respiratory distress syndrome: the heterogeneous effects |
title_full | Positive end-expiratory pressure in COVID-19 acute respiratory distress syndrome: the heterogeneous effects |
title_fullStr | Positive end-expiratory pressure in COVID-19 acute respiratory distress syndrome: the heterogeneous effects |
title_full_unstemmed | Positive end-expiratory pressure in COVID-19 acute respiratory distress syndrome: the heterogeneous effects |
title_short | Positive end-expiratory pressure in COVID-19 acute respiratory distress syndrome: the heterogeneous effects |
title_sort | positive end-expiratory pressure in covid-19 acute respiratory distress syndrome: the heterogeneous effects |
topic | Research |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8674862/ https://www.ncbi.nlm.nih.gov/pubmed/34915911 http://dx.doi.org/10.1186/s13054-021-03839-4 |
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