Mittermaier Mirja, Pickerodt Philipp, Kurth Florian, de Jarcy Laure Bosquillon, Uhrig Alexander, Garcia Carmen, Machleidt Felix, Pergantis Panagiotis, Weber Susanne, Li Yaosi, Breitbart Astrid, Bremer Felix, Knape Philipp, Dewey Marc, Doellinger Felix, Weber-Carstens Steffen, Slutsky Arthur S, Kuebler Wolfgang M, Suttorp Norbert, Müller-Redetzky Holger
Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
Berlin Institute of Health, Berlin, Germany.
EClinicalMedicine. 2020 Nov;28:100579. doi: 10.1016/j.eclinm.2020.100579. Epub 2020 Oct 11.
In face of the Coronavirus Disease (COVID)-19 pandemic, best practice for mechanical ventilation in COVID-19 associated Acute Respiratory Distress Syndrome (ARDS) is intensely debated. Specifically, the rationale for high positive end-expiratory pressure (PEEP) and prone positioning in early COVID-19 ARDS has been questioned.
The first 23 consecutive patients with COVID-19 associated respiratory failure transferred to a single ICU were assessed. Eight were excluded: five were not invasively ventilated and three received veno-venous ECMO support. The remaining 15 were assessed over the first 15 days of mechanical ventilation. Best PEEP was defined by maximal oxygenation and was determined by structured decremental PEEP trials comprising the monitoring of oxygenation, airway pressures and trans-pulmonary pressures. In nine patients the impact of prone positioning on oxygenation was investigated. Additionally, the effects of high PEEP and prone positioning on pulmonary opacities in serial chest x-rays were determined by applying a semiquantitative scoring-system. This investigation is part of the prospective observational PA-COVID-19 study.
Patients responded to initiation of invasive high PEEP ventilation with markedly improved oxygenation, which was accompanied by reduced pulmonary opacities within 6 h of mechanical ventilation. Decremental PEEP trials confirmed the need for high PEEP (17.9 (SD ± 3.9) mbar) for optimal oxygenation, while driving pressures remained low. Prone positioning substantially increased oxygenation (<0.01).
In early COVID-19 ARDS, substantial PEEP values were required for optimizing oxygenation. Pulmonary opacities resolved during mechanical ventilation with high PEEP suggesting recruitment of lung volume.
German Research Foundation, German Federal Ministry of Education and Research.
面对新型冠状病毒肺炎（COVID-19）大流行，COVID-19相关急性呼吸窘迫综合征（ARDS）机械通气的最佳实践引发了激烈争论。具体而言，早期COVID-19 ARDS中高呼气末正压（PEEP）和俯卧位通气的理论依据受到质疑。
对连续转诊至单个重症监护病房（ICU）的首批23例COVID-19相关呼吸衰竭患者进行评估。8例被排除：5例未接受有创通气，3例接受静脉-静脉体外膜肺氧合（ECMO）支持。其余15例在机械通气的前15天进行评估。最佳PEEP通过最大氧合来定义，并通过结构化递减PEEP试验确定，该试验包括监测氧合、气道压力和跨肺压。对9例患者研究了俯卧位通气对氧合的影响。此外，通过应用半定量评分系统确定高PEEP和俯卧位通气对系列胸部X线片上肺部混浊的影响。本研究是前瞻性观察性PA-COVID-19研究的一部分。
患者对有创高PEEP通气的启动反应为氧合显著改善，同时在机械通气6小时内肺部混浊减轻。递减PEEP试验证实，为实现最佳氧合需要高PEEP（17.9（标准差±3.9）毫巴），而驱动压保持较低。俯卧位通气显著提高了氧合（P<0.01）。
在早期COVID-19 ARDS中，需要较高的PEEP值来优化氧合。在高PEEP机械通气期间肺部混浊消失，提示肺容积复张。
德国研究基金会、德国联邦教育与研究部。
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