Positive end-expiratory pressure titration in COVID-19 acute respiratory failure: electrical impedance tomography vs. PE
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RESEARCH LETTER
Open Access
Positive end-expiratory pressure titration in COVID-19 acute respiratory failure: electrical impedance tomography vs. PEEP/FiO2 tables Nicolò Sella1†, Francesco Zarantonello2†, Giulio Andreatta1, Veronica Gagliardi1, Annalisa Boscolo2 and Paolo Navalesi1,2*
Keywords: COVID-19, Acute respiratory failure, Mechanical ventilation, Positive end-expiratory pressure, Electrical impedance tomography To the Editor, Hypoxemic acute respiratory failure (hARF) secondary to COVID-19 presents with heterogeneous features depending on several determinants, such as the extent of intravascular microthrombosis, superinfections, and other complications [1, 2]. The easiest approach for setting positive end-expiratory pressure (PEEP) and inspiratory oxygen fraction (FiO2) is using PEEP/FiO2 tables [3, 4]. However, because the magnitude of lung recruitability is variable, personalizing PEEP would be desirable [1]. Electrical impedance tomography (EIT) offers this opportunity by bedside estimating both alveolar collapse and lung overdistension throughout a decremental PEEP trial [5]. This investigation (Ethics Committee approval: Ref: 4853/AO/20-AOP2012) aims to assess the agreement between EIT-based PEEP values and those recommended by the higher and lower PEEP/FiO2 tables [6] in a series of consecutive intubated COVID-19 hARF patients, admitted to intensive care unit at our institution. Written informed consent was obtained from all patients. * Correspondence: [email protected] † Nicolò Sella and Francesco Zarantonello contributed equally to this work. 1 Department of Medicine - DIMEDD, University of Padua, via V. Gallucci 13, 35125 Padua, Italy 2 Anaesthesia and Intensive Care Unit, Padua University Hospital, via V. Gallucci 13, 35125 Padua, Italy
We performed 15 decremental PEEP trials through a dedicated device (Pulmovista500, Dr ger-Medical, Germany) and subsequently analyzed pulmonary perfusion distribution [5]. Five patients were evaluated in a prone position. EIT optimal PEEP (PEEPEIT) was defined as the best compromise between lung collapse and overdistension [5]. All patients were deeply sedated without spontaneous breathing efforts and ventilated in volume control mode with lung-protective settings [3]. PEEPEIT was compared with PEEP from higher and lower PEEP/ FiO2 tables [6]. Data, expressed as median and interquartile ranges or 95% confidence interval (CI), were analyzed with the Mann–Whitney test for comparisons and Spearman rank test for correlations, considering p values < 0.05 significant. The Bland–Alman analysis was also performed. Patients had received invasive ventilation for 12.0 (10.0–14.5) days. Patients’ age was 63 (56–78) years, while body mass index (BMI) was 26.2 (25.4–30.9) kg/ m2. Pulmonary shunt and dead space, as assessed by EIT [5], were 4% (2–6%) and 27% (23–36%), respectively. Ddimer was increased [759 (591–1208) mcg/L], while procalcitonin blood concentration was nearly normal [0.53 (0.34–0.70) mcg/L]. PEEPEIT was 12 (10–14) cmH2O and was significantly different f
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