Variation of poorly ventilated lung units (silent spaces) measured by electrical impedance tomography to dynamically assess recruitment.

BACKGROUND

Assessing alveolar recruitment at different positive end-expiratory pressure (PEEP) levels is a major clinical and research interest because protective ventilation implies opening the lung without inducing overdistention. The pressure-volume (P-V) curve is a validated method of assessing recruitment but reflects global characteristics, and changes at the regional level may remain undetected. The aim of the present study was to compare, in intubated patients with acute hypoxemic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS), lung recruitment measured by P-V curve analysis, with dynamic changes in poorly ventilated units of the dorsal lung (dependent silent spaces [DSSs]) assessed by electrical impedance tomography (EIT). We hypothesized that DSSs might represent a dynamic bedside measure of recruitment.

METHODS

We carried out a prospective interventional study of 14 patients with AHRF and ARDS admitted to the intensive care unit undergoing mechanical ventilation. Each patient underwent an incremental/decremental PEEP trial that included five consecutive phases: PEEP 5 and 10 cmHO, recruitment maneuver + PEEP 15 cmHO, then PEEP 10 and 5 cmHO again. We measured, at the end of each phase, recruitment from previous PEEP using the P-V curve method, and changes in DSS were continuously monitored by EIT.

RESULTS

PEEP changes induced alveolar recruitment as assessed by the P-V curve method and changes in the amount of DSS (p < 0.001). Recruited volume measured by the P-V curves significantly correlated with the change in DSS (r = 0.734, p < 0.001). Regional compliance of the dependent lung increased significantly with rising PEEP (median PEEP 5 cmHO = 11.9 [IQR 10.4-16.7] ml/cmHO, PEEP 15 cmHO = 19.1 [14.2-21.3] ml/cmHO; p < 0.001), whereas regional compliance of the nondependent lung decreased from PEEP 5 cmHO to PEEP 15 cmHO (PEEP 5 cmHO = 25.3 [21.3-30.4] ml/cmHO, PEEP 15 cmHO = 20.0 [16.6-22.8] ml/cmHO; p <0.001). By increasing the PEEP level, the center of ventilation moved toward the dependent lung, returning to the nondependent lung during the decremental PEEP steps.

CONCLUSIONS

The variation of DSSs dynamically measured by EIT correlates well with lung recruitment measured using the P-V curve technique. EIT might provide useful information to titrate personalized PEEP.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02907840 . Registered on 20 September 2016.