PEEP titration in moderate to severe ARDS: plateau versus transpulmonary pressure

Abstract

Abstract Background Although lung protection with low tidal volume and limited plateau pressure (P plat) improves survival in acute respiratory distress syndrome patients (ARDS), the best way to set positive end-expiratory pressure (PEEP) is still debated. Methods This study aimed to compare two strategies using individual PEEP based on a maximum P plat (28–30 cmH2O, the Express group) or on keeping end-expiratory transpulmonary pressure positive (0–5 cmH2O, P Lexpi group). We estimated alveolar recruitment (Vrec), end-expiratory lung volume and alveolar distension based on elastance-related end-inspiratory transpulmonary pressure (P L,EL). Results Nineteen patients with moderate to severe ARDS (PaO2/FiO2 25 cmH2O. Conclusions There is a great heterogeneity of P Lexpi when P plat is used to titrate PEEP but with limited risk of over-distension. A PEEP titration for a moderate positive level of P Lexpi might slightly improve alveolar recruitment and oxygenation but increases the risk of over-distension in one-third of patients.

Keywords

• ARDS
• PEEP titration
• Monitoring
• Transpulmonary pressure