基于电阻抗断层成像技术在接受静脉-静脉体外膜肺氧合治疗的重症急性呼吸窘迫综合征患者中确定最佳呼气末正压及复张与充气比

Optimum electrical impedance tomography-based PEEP and recruitment-to-inflation ratio in patients with severe ARDS on venovenous ECMO.

作者信息

Coppens Alexandre, Aissi James Sarah, Roze Hadrien, Juvin Charles, Repusseau Benjamin, Lebreton Guillaume, Luyt Charles-Edouard, Hékimian Guillaume, Chommeloux Juliette, Pineton de Chambrun Marc, Combes Alain, Franchineau Guillaume, Schmidt Matthieu

机构信息

UMRS_1166-ICAN, Service de Medecine Intensive Reanimation, iCAN, Institute of Cardiometabolism and Nutrition, INSERM, Hôpital de la Pitié-Salpêtrière, Sorbonne Universités, 47, Bd de L'Hôpital, 75651, Paris Cedex 13, France.

Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, 75651, Paris Cedex 13, France.

出版信息

Crit Care. 2025 May 16;29(1):195. doi: 10.1186/s13054-025-05437-0.

DOI:10.1186/s13054-025-05437-0

PMID:40380232

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC12084998/

Abstract

RATIONALE

The significance of the Recruitment to Inflation (R/I) ratio in identifying PEEP recruiters in patients undergoing ultra-protective lung ventilation during venovenous ECMO is not well established.

OBJECTIVES

To compare the concordance of the R/I ratio and Electrical Impedance Tomography (EIT) in determining optimum PEEP settings in severe ARDS patients on ECMO and ventilated with very low tidal volumes.

METHODS

Initially, a low-flow insufflation was performed to detect and measure the airway opening pressure (AOP). Subsequently, the R/I ratio was calculated from PEEP 15-5 cmHO, followed by a decremental PEEP trial (20-6 cmHO in 2 cmHO steps) monitored by EIT. The optimum EIT-based PEEP was defined as the intersection of the collapse and overdistension curves.

MAIN RESULTS

Among 54 ECMO patients (tidal volume: 4.8 [3.0-6.0] mL/kg), 13 (24%) exhibited an airway opening pressure (AOP) of 11 (8-14) cmHO. The cohort's median R/I ratio was 0.43 (0.28-0.61). A tertile-based analysis of the R/I ratio (≤ 0.34; 0.34-0.54; > 0.54) revealed median optimum EIT-based PEEP of 8 [8-10], 10 [8-14], and 14 [12-16] cmHO, respectively. The R/I ratio demonstrated weak inverse correlations with lung overdistension (R = 0.19) and positive correlations with lung collapse (R = 0.26) measured by EIT (p < 0.01).

CONCLUSION

The R/I ratio is feasible during ultra-protective ventilation and provides valuable indications for guiding PEEP titration. Specifically, an R/I ratio > 0.34 may help identify patients likely to benefit from further individualized PEEP optimization using EIT. In contrast, when the R/I ratio is ≤ 0.34, a moderate PEEP level (8-10 cmH₂O) may suffice.

摘要

原理

在静脉-静脉体外膜肺氧合（venovenous ECMO）期间进行超保护性肺通气的患者中，募集与膨胀（R/I）比值在识别可复张肺区域方面的意义尚未明确。

目的

比较R/I比值与电阻抗断层扫描（EIT）在确定接受ECMO且采用低潮气量通气的重症急性呼吸窘迫综合征（ARDS）患者最佳呼气末正压（PEEP）设置时的一致性。

方法

首先，进行低流量充气以检测和测量气道开口压力（AOP）。随后，从PEEP 15至5 cmH₂O计算R/I比值，接着进行由EIT监测的递减PEEP试验（从20至6 cmH₂O，每次递减2 cmH₂O）。基于EIT的最佳PEEP定义为肺萎陷和过度膨胀曲线的交点。

主要结果

在54例接受ECMO的患者中（潮气量：4.8 [3.0 - 6.0] mL/kg），13例（24%）的气道开口压力（AOP）为11（8 - 14）cmH₂O。该队列的R/I比值中位数为0.43（0.28 - 0.61）。基于三分位数对R/I比值进行分析（≤ 0.34；0.34 - 0.54；> 0.54），结果显示基于EIT的最佳PEEP中位数分别为8 [8 - 10]、10 [8 - 14]和14 [12 - 16] cmH₂O。R/I比值与EIT测量的肺过度膨胀呈弱负相关（R = 0.19），与肺萎陷呈正相关（R = 0.26）（p < 0.01）。