Mortality and pulmonary mechanics in relation to respiratory system and transpulmonary driving pressures in ARDS
- 4.9k Downloads
The driving pressure of the respiratory system has been shown to strongly correlate with mortality in a recent large retrospective ARDSnet study. Respiratory system driving pressure [plateau pressure−positive end-expiratory pressure (PEEP)] does not account for variable chest wall compliance. Esophageal manometry can be utilized to determine transpulmonary driving pressure. We have examined the relationships between respiratory system and transpulmonary driving pressure, pulmonary mechanics and 28-day mortality.
Fifty-six patients from a previous study were analyzed to compare PEEP titration to maintain positive transpulmonary end-expiratory pressure to a control protocol. Respiratory system and transpulmonary driving pressures and pulmonary mechanics were examined at baseline, 5 min and 24 h. Analysis of variance and linear regression were used to compare 28 day survivors versus non-survivors and the intervention group versus the control group, respectively.
At baseline and 5 min there was no difference in respiratory system or transpulmonary driving pressure. By 24 h, survivors had lower respiratory system and transpulmonary driving pressures. Similarly, by 24 h the intervention group had lower transpulmonary driving pressure. This decrease was explained by improved elastance and increased PEEP.
The results suggest that utilizing PEEP titration to target positive transpulmonary pressure via esophageal manometry causes both improved elastance and driving pressures. Treatment strategies leading to decreased respiratory system and transpulmonary driving pressure at 24 h may be associated with improved 28 day mortality. Studies to clarify the role of respiratory system and transpulmonary driving pressures as a prognosticator and bedside ventilator target are warranted.
KeywordsARDS Driving pressure Esophageal manometry Transpulmonary driving pressure Respiratory system driving pressure Mortality
The authors acknowledge Robert Gerber for assistance in making the figures and Victor Novak for assistance with statistical analysis. There was no separate funding source for this study, however the original EPVent study was funded under Stephen Lorings RO1 Grant HL-52586.
Compliance with ethical standards
Conflicts of interest
The authors declare that they have no conflicts of interest.
- 8.Villar J, Kacmarek RM, Perez-Mendez L, Aguirre-Jaime A (2006) A high positive end-expiratory pressure, low tidal volume ventilatory strategy improves outcome in persistent acute respiratory distress syndrome: a randomized, controlled trial. Crit Care Med 34:1311–1318. doi: 10.1097/01.CCM.0000215598.84885.01 CrossRefPubMedGoogle Scholar
- 21.Meade MO, Cook DJ, Guyatt GH et al (2008) Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 299:637–645. doi: 10.1001/jama.299.6.637 CrossRefPubMedGoogle Scholar
- 29.Eisner MD, Thompson BT, Schoenfeld D, Anzueto A, Matthay MA, Network Acute Respiratory Distress Syndrome (2002) Airway pressures and early barotrauma in patients with acute lung injury and acute respiratory distress syndrome. Am J Respir Crit Care Med 165:978–982. doi: 10.1164/ajrccm.165.7.2109059 CrossRefPubMedGoogle Scholar