Lung Response to a Higher Positive End-Expiratory Pressure in Mechanically Ventilated Patients With COVID-19,Chest

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Lung Response to a Higher Positive End-Expiratory Pressure in Mechanically Ventilated Patients With COVID-19
Chest ( IF 9.5 ) Pub Date : 2021-10-16 , DOI: 10.1016/j.chest.2021.10.012
Alessandro Protti ₁ , Alessandro Santini ₂ , Francesca Pennati ₃ , Chiara Chiurazzi ₂ , Massimo Cressoni ₄ , Michele Ferrari ₂ , Giacomo E Iapichino ₂ , Luca Carenzo ₂ , Ezio Lanza ₅ , Giorgio Picardo ₆ , Pietro Caironi ₇ , Andrea Aliverti ₃ , Maurizio Cecconi ₁

Affiliation

Background

International guidelines suggest using a higher (> 10 cm H₂O) positive end-expiratory pressure (PEEP) in patients with moderate-to-severe ARDS due to COVID-19. However, even if oxygenation generally improves with a higher PEEP, compliance, and Paco₂ frequently do not, as if recruitment was small.

Research Question

Is the potential for lung recruitment small in patients with early ARDS due to COVID-19?

Study Design and Methods

Forty patients with ARDS due to COVID-19 were studied in the supine position within 3 days of endotracheal intubation. They all underwent a PEEP trial, in which oxygenation, compliance, and Paco₂ were measured with 5, 10, and 15 cm H₂O of PEEP, and all other ventilatory settings unchanged. Twenty underwent a whole-lung static CT scan at 5 and 45 cm H₂O, and the other 20 at 5 and 15 cm H₂O of airway pressure. Recruitment and hyperinflation were defined as a decrease in the volume of the non-aerated (density above −100 HU) and an increase in the volume of the over-aerated (density below −900 HU) lung compartments, respectively.

Results

From 5 to 15 cm H₂O, oxygenation improved in 36 (90%) patients but compliance only in 11 (28%) and Paco₂ only in 14 (35%). From 5 to 45 cm H₂O, recruitment was 351 (161-462) mL and hyperinflation 465 (220-681) mL. From 5 to 15 cm H₂O, recruitment was 168 (110-202) mL and hyperinflation 121 (63-270) mL. Hyperinflation variably developed in all patients and exceeded recruitment in more than half of them.

Interpretation

Patients with early ARDS due to COVID-19, ventilated in the supine position, present with a large potential for lung recruitment. Even so, their compliance and Paco₂ do not generally improve with a higher PEEP, possibly because of hyperinflation.

中文翻译：

COVID-19 机械通气患者对较高呼气末正压的肺反应

背景

国际指南建议对因 COVID-19 导致的中度至重度 ARDS 患者使用更高（> 10 cm H ₂ O）的呼气末正压 (PEEP)。然而，即使氧合通常随着更高的 PEEP 改善，顺应性和 Pa co ₂也经常没有，好像肺复张很少。

研究问题

COVID-19 导致的早期 ARDS 患者肺复张的可能性是否很小？

研究设计和方法

在气管插管后 3 天内，对 40 名因 COVID-19 导致的 ARDS 患者进行了仰卧位研究。他们都接受了 PEEP 试验，其中在5、10 和 15 cm H ₂ O 的 PEEP 和所有其他通气设置不变的情况下测量氧合、顺应性和 Pa co _{2 。}_{20 名在 5 和 45 cm H 2} O下进行了全肺静态 CT 扫描，另外 20 名在 5 和 15 cm H ₂ O 气道压力下进行了全肺静态 CT 扫描。肺复张和过度充气分别定义为未充气（密度高于-100 HU）的体积减少和过度充气（密度低于-900 HU）肺隔室的体积增加。

结果

从 5 到 15 cm H ₂ O，36 名 (90%) 患者的氧合得到改善，但仅 11 名 (28%) 患者的合规性和 Paco ₂仅在 14 名 (35%) 患者中得到改善。从 5 到 45 cm H ₂ O，募集量为 351 (161-462) mL，过度充气量为 465 (220-681) mL。从 5 到 15 cm H ₂ O，募集量为 168 (110-202) mL，过度充气量为 121 (63-270) mL。所有患者都出现恶性通货膨胀，其中一半以上的患者出现过度通货膨胀。