Effect of external PEEP in patients under controlled mechanical ventilation with an auto-PEEP of 5 cmH2O or higher
BACKGROUND: In some patients with auto-positive end-expiratory pressure (auto-PEEP), application of PEEP lower than auto-PEEP maintains a constant total PEEP, therefore reducing the inspiratory threshold load without detrimental cardiovascular or respiratory effects. We refer to these patients as "complete PEEP-absorbers." Conversely, adverse effects of PEEP application could occur in patients with auto-PEEP when the total PEEP rises as a consequence. From a pathophysiological perspective, all subjects with flow limitation are expected to be "complete PEEP-absorbers," whereas PEEP should increase total PEEP in all other patients. This study aimed to empirically assess the extent to which flow limitation alone explains a "complete PEEP-absorber" behavior (i.e., absence of further hyperinflation with PEEP), and to identify other factors associated with it.
METHODS: One hundred patients with auto-PEEP of at least 5 cmH2O at zero end-expiratory pressure (ZEEP) during controlled mechanical ventilation were enrolled. Total PEEP (i.e., end-expiratory plateau pressure) was measured both at ZEEP and after applied PEEP equal to 80 % of auto-PEEP measured at ZEEP. All measurements were repeated three times, and the average value was used for analysis.
RESULTS: Forty-seven percent of the patients suffered from chronic pulmonary disease and 52 % from acute pulmonary disease; 61 % showed flow limitation at ZEEP, assessed by manual compression of the abdomen. The mean total PEEP was 7 ± 2 cmH2O at ZEEP and 9 ± 2 cmH2O after the application of PEEP (p < 0.001). Thirty-three percent of the patients were "complete PEEP-absorbers." Multiple logistic regression was used to predict the behavior of "complete PEEP-absorber." The best model included a respiratory rate lower than 20 breaths/min and the presence of flow limitation. The predictive ability of the model was excellent, with an overoptimism-corrected area under the receiver operating characteristics curve of 0.89 (95 % CI 0.80-0.97).
CONCLUSIONS: Expiratory flow limitation was associated with both high and complete "PEEP-absorber" behavior, but setting a relatively high respiratory rate on the ventilator can prevent from observing complete "PEEP-absorption." Therefore, the effect of PEEP application in patients with auto-PEEP can be accurately predicted at the bedside by measuring the respiratory rate and observing the flow-volume loop during manual compression of the abdomen.
| Medienart: |
E-Artikel |
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| Erscheinungsjahr: |
2016 |
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| Erschienen: |
2016 |
| Enthalten in: |
Zur Gesamtaufnahme - volume:6 |
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| Enthalten in: |
Annals of intensive care - 6(2016), 1 vom: 15. Dez., Seite 53 |
| Sprache: |
Englisch |
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| Beteiligte Personen: |
Natalini, Giuseppe [VerfasserIn] |
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| Links: |
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| Themen: |
Auto-positive end-expiratory pressure |
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| Anmerkungen: |
Date Completed 16.06.2016 Date Revised 01.10.2020 published: Print-Electronic Citation Status PubMed-not-MEDLINE |
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| doi: |
10.1186/s13613-016-0158-0 |
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| funding: |
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| Förderinstitution / Projekttitel: |
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| 100 | 1 | |a Natalini, Giuseppe |e verfasserin |4 aut | |
| 245 | 1 | 0 | |a Effect of external PEEP in patients under controlled mechanical ventilation with an auto-PEEP of 5 cmH2O or higher |
| 264 | 1 | |c 2016 | |
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| 500 | |a Date Revised 01.10.2020 | ||
| 500 | |a published: Print-Electronic | ||
| 500 | |a Citation Status PubMed-not-MEDLINE | ||
| 520 | |a BACKGROUND: In some patients with auto-positive end-expiratory pressure (auto-PEEP), application of PEEP lower than auto-PEEP maintains a constant total PEEP, therefore reducing the inspiratory threshold load without detrimental cardiovascular or respiratory effects. We refer to these patients as "complete PEEP-absorbers." Conversely, adverse effects of PEEP application could occur in patients with auto-PEEP when the total PEEP rises as a consequence. From a pathophysiological perspective, all subjects with flow limitation are expected to be "complete PEEP-absorbers," whereas PEEP should increase total PEEP in all other patients. This study aimed to empirically assess the extent to which flow limitation alone explains a "complete PEEP-absorber" behavior (i.e., absence of further hyperinflation with PEEP), and to identify other factors associated with it | ||
| 520 | |a METHODS: One hundred patients with auto-PEEP of at least 5 cmH2O at zero end-expiratory pressure (ZEEP) during controlled mechanical ventilation were enrolled. Total PEEP (i.e., end-expiratory plateau pressure) was measured both at ZEEP and after applied PEEP equal to 80 % of auto-PEEP measured at ZEEP. All measurements were repeated three times, and the average value was used for analysis | ||
| 520 | |a RESULTS: Forty-seven percent of the patients suffered from chronic pulmonary disease and 52 % from acute pulmonary disease; 61 % showed flow limitation at ZEEP, assessed by manual compression of the abdomen. The mean total PEEP was 7 ± 2 cmH2O at ZEEP and 9 ± 2 cmH2O after the application of PEEP (p < 0.001). Thirty-three percent of the patients were "complete PEEP-absorbers." Multiple logistic regression was used to predict the behavior of "complete PEEP-absorber." The best model included a respiratory rate lower than 20 breaths/min and the presence of flow limitation. The predictive ability of the model was excellent, with an overoptimism-corrected area under the receiver operating characteristics curve of 0.89 (95 % CI 0.80-0.97) | ||
| 520 | |a CONCLUSIONS: Expiratory flow limitation was associated with both high and complete "PEEP-absorber" behavior, but setting a relatively high respiratory rate on the ventilator can prevent from observing complete "PEEP-absorption." Therefore, the effect of PEEP application in patients with auto-PEEP can be accurately predicted at the bedside by measuring the respiratory rate and observing the flow-volume loop during manual compression of the abdomen | ||
| 650 | 4 | |a Journal Article | |
| 650 | 4 | |a Auto-positive end-expiratory pressure | |
| 650 | 4 | |a Dynamic hyperinflation | |
| 650 | 4 | |a Flow limitation | |
| 650 | 4 | |a Mechanical ventilation | |
| 650 | 4 | |a Positive end-expiratory pressure | |
| 650 | 4 | |a Respiratory rate | |
| 700 | 1 | |a Tuzzo, Daniele |e verfasserin |4 aut | |
| 700 | 1 | |a Rosano, Antonio |e verfasserin |4 aut | |
| 700 | 1 | |a Testa, Marco |e verfasserin |4 aut | |
| 700 | 1 | |a Grazioli, Michele |e verfasserin |4 aut | |
| 700 | 1 | |a Pennestrì, Vincenzo |e verfasserin |4 aut | |
| 700 | 1 | |a Amodeo, Guido |e verfasserin |4 aut | |
| 700 | 1 | |a Berruto, Francesco |e verfasserin |4 aut | |
| 700 | 1 | |a Fiorillo, Marialinda |e verfasserin |4 aut | |
| 700 | 1 | |a Peratoner, Alberto |e verfasserin |4 aut | |
| 700 | 1 | |a Tinnirello, Andrea |e verfasserin |4 aut | |
| 700 | 1 | |a Filippini, Matteo |e verfasserin |4 aut | |
| 700 | 1 | |a Marsilia, Paolo F |e verfasserin |4 aut | |
| 700 | 1 | |a Minelli, Cosetta |e verfasserin |4 aut | |
| 700 | 1 | |a Bernardini, Achille |e verfasserin |4 aut | |
| 700 | 0 | |a VENTILAB group |e verfasserin |4 aut | |
| 700 | 1 | |a Albani, Filippo |e investigator |4 oth | |
| 700 | 1 | |a Alfieri, Maria |e investigator |4 oth | |
| 700 | 1 | |a Amicucci, Giovanni |e investigator |4 oth | |
| 700 | 1 | |a Buizza, Barbara |e investigator |4 oth | |
| 700 | 1 | |a de Cristofaro, Maria Giovanna |e investigator |4 oth | |
| 700 | 1 | |a Ferrari, Antonella |e investigator |4 oth | |
| 700 | 1 | |a Granato, Anna |e investigator |4 oth | |
| 700 | 1 | |a Iannaco, Irene |e investigator |4 oth | |
| 700 | 1 | |a Latronico, Nicola |e investigator |4 oth | |
| 700 | 1 | |a Lucangelo, Umberto |e investigator |4 oth | |
| 700 | 1 | |a Mendetta, Luigi |e investigator |4 oth | |
| 700 | 1 | |a Todeschini, Manuel |e investigator |4 oth | |
| 700 | 1 | |a Tomasoni, Gabriele |e investigator |4 oth | |
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