Respiratory failure & ventilation
High vs Low Positive End-expiratory Pressure (PEEP) in Patients With ARDS Exhibiting Intense Inspiratory Effort During Assisted Ventilation: A Randomized Crossover Trial
Authors' conclusion
The impact of high PEEP on ΔPes and lung stress is interindividually variable according to different effects on the respiratory system and lung compliance resulting from alveolar overinflation.
Study context
- Population
- Moderate-to-severe ARDS on assisted ventilation with PaO2/FiO2 ≤ 200 mm Hg and inspiratory effort (ΔPes) ≥ 10 cm H2Ocrossover
- Participants
- 16 participants
- Comparison
- PEEP 15 vs 5 cm H2O, each with PSV or PC-IMV
- Primary endpoint
- Inspiratory effort (ΔPes)
Methodological detailsrandomized sequence of four ventilator settings, esophageal manometry, electrical impedance tomography
- Randomized sequence of four ventilator settings
- Esophageal manometry
- Electrical impedance tomography
Primary result
As reported in the abstract
High PEEP + PSV
20
median · IQR 15–24 · cm H2O
Low PEEP + PSV
15
median · IQR 13–23 · cm H2O
High PEEP + PC-IMV
20
median · IQR 18–23
Low PEEP + PC-IMV
19
median · IQR 17–25
High PEEP + PSV vs Low PEEP + PSV: P = 0.24 · High PEEP + PC-IMV vs Low PEEP + PC-IMV: P = 0.67
Further findings
Median
| Outcome | High PEEP + PSV | Low PEEP + PSV | High PEEP + PC-IMV | Low PEEP + PC-IMV | P value |
|---|---|---|---|---|---|
| Dynamic strain in ventral lung areasHigh PEEP + PSV vs Low PEEP + PSV | 0.49 (IQR 0.37–0.83) | 0.96 (IQR 0.62–1.56) | 0.65 (IQR 0.42–1.31) | 1.14 (IQR 0.79–1.52) | P = 0.003 |
| Dynamic strain in ventral lung areasHigh PEEP + PC-IMV vs Low PEEP + PC-IMV | P = 0.002 |
- Dynamic strain in ventral lung areas: results consistent during synchronous and asynchronous assistance
Respiratory system and transpulmonary driving pressures, tidal volume, lung/chest wall mechanics, pendelluft
- Not different between study phases
Correlation of PEEP-induced change in respiratory system compliance with change in ΔPes, respiratory system and transpulmonary driving pressure
- ΔPes: r
- −0.85
- ΔPes: P
- P < 0.001
- Respiratory system driving pressure: r
- −0.75
- Respiratory system driving pressure: P
- P < 0.001
- Transpulmonary driving pressure: r
- −0.80
- Transpulmonary driving pressure: P
- P < 0.001
- High PEEP lowered or raised these according to whether it increased or decreased compliance
Dependence of compliance change on PEEP-induced alveolar overinflation
- R
- −0.66
- P
- P = 0.006
- Compliance changes driven by lung component
Dynamic strain in ventral lung areas
- High PEEP caused variable recruitment and systematic redistribution of tidal volume toward dorsal regions
Original publication
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