Boesing Christoph, Graf Peter T, Schmitt Fabian, Thiel Manfred, Pelosi Paolo, Rocco Patricia R M, Luecke Thomas, Krebs Joerg
Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany.
Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
Crit Care. 2022 Mar 26;26(1):82. doi: 10.1186/s13054-022-03956-8.
Prone positioning in combination with the application of low tidal volume and adequate positive end-expiratory pressure (PEEP) improves survival in patients with moderate to severe acute respiratory distress syndrome (ARDS). However, the effects of PEEP on end-expiratory transpulmonary pressure (Ptp) during prone positioning require clarification. For this purpose, the effects of three different PEEP titration strategies on Ptp, respiratory mechanics, mechanical power, gas exchange, and hemodynamics were evaluated comparing supine and prone positioning.
In forty consecutive patients with moderate to severe ARDS protective ventilation with PEEP titrated according to three different titration strategies was evaluated during supine and prone positioning: (A) ARDS Network recommendations (PEEP), (B) the lowest static elastance of the respiratory system (PEEP), and (C) targeting a positive Ptp (PEEP). The primary endpoint was to analyze whether Ptp differed significantly according to PEEP titration strategy during supine and prone positioning.
Ptp increased progressively with prone positioning compared with supine positioning as well as with PEEP and PEEP compared with PEEP (positioning effect p < 0.001, PEEP strategy effect p < 0.001). PEEP was lower during prone positioning with PEEP and PEEP (positioning effect p < 0.001, PEEP strategy effect p < 0.001). During supine positioning, mechanical power increased progressively with PEEP and PEEP compared with PEEP, and prone positioning attenuated this effect (positioning effect p < 0.001, PEEP strategy effect p < 0.001). Prone compared with supine positioning significantly improved oxygenation (positioning effect p < 0.001, PEEP strategy effect p < 0.001) while hemodynamics remained stable in both positions.
Prone positioning increased transpulmonary pressures while improving oxygenation and hemodynamics in patients with moderate to severe ARDS when PEEP was titrated according to the ARDS Network lower PEEP table. This PEEP titration strategy minimized parameters associated with ventilator-induced lung injury induction, such as transpulmonary driving pressure and mechanical power. We propose that a lower PEEP strategy (PEEP) in combination with prone positioning may be part of a lung protective ventilation strategy in patients with moderate to severe ARDS.
German Clinical Trials Register ( DRKS00017449 ). Registered June 27, 2019. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017449.
俯卧位联合低潮气量及适当的呼气末正压（PEEP）可提高中重度急性呼吸窘迫综合征（ARDS）患者的生存率。然而，俯卧位时PEEP对呼气末跨肺压（Ptp）的影响尚需阐明。为此，比较仰卧位和俯卧位时，评估了三种不同PEEP滴定策略对Ptp、呼吸力学、机械功率、气体交换及血流动力学的影响。
连续纳入40例中重度ARDS患者，在仰卧位和俯卧位时，根据三种不同的滴定策略对PEEP进行滴定，以实施保护性通气：（A）ARDS网络推荐（PEEP）；（B）呼吸系统最低静态弹性（PEEP）；（C）目标为正的Ptp（PEEP）。主要终点是分析仰卧位和俯卧位时，Ptp根据PEEP滴定策略是否有显著差异。
与仰卧位相比，俯卧位时Ptp逐渐升高，与PEEP及PEEP相比，PEEP时Ptp也升高（体位效应p＜0.001，PEEP策略效应p＜0.001）。PEEP及PEEP时俯卧位的PEEP较低（体位效应p＜0.001，PEEP策略效应p＜0.001）。仰卧位时，与PEEP相比，PEEP及PEEP时机械功率逐渐升高，俯卧位减弱了这种效应（体位效应p＜0.001，PEEP策略效应p＜0.001）。与仰卧位相比，俯卧位显著改善氧合（体位效应p＜0.001，PEEP策略效应p＜0.001），而两个体位的血流动力学均保持稳定。
当根据ARDS网络较低PEEP表格滴定PEEP时，俯卧位可增加中重度ARDS患者的跨肺压，同时改善氧合和血流动力学。这种PEEP滴定策略使与呼吸机诱导肺损伤相关的参数（如跨肺驱动压和机械功率）降至最低。我们建议，较低PEEP策略（PEEP）联合俯卧位可能是中重度ARDS患者肺保护性通气策略的一部分。
德国临床试验注册中心（DRKS00017449）。2019年6月27日注册。https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017449。
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