Abstract
Electrical Impedance Tomography (EIT) is a novel real-time lung imaging technology for personalized ventilation adjustments, indicating promising results in animals and humans. The present study aimed to assess its clinical utility for improved ventilation and oxygenation compared to traditional protocols. Comprehensive electronic database screening was done until 30th November, 2023. Randomized controlled trials, controlled clinical trials, comparative cohort studies, and assessments of EIT-guided PEEP titration and conventional methods in adult ARDS patients regarding outcome, ventilatory parameters, and P/F ratio were included. Our search retrieved five controlled cohort studies and two RCTs with 515 patients and overall reduced risk of mortality [RR = 0.68; 95% CI: 0.49 to 0.95; I2 = 0%], better dynamic compliance [MD = 3.46; 95% CI: 1.59 to 5.34; I2 = 0%] with no significant difference in PaO2/FiO2 ratio [MD = 6.5; 95%CI -13.86 to 26.76; I2 = 74%]. The required information size except PaO2/FiO2 was achieved for a power of 95% based on the 50% reduction in risk of mortality, 10% improved compliance as the cumulative Z-score of the said outcomes crossed the alpha spending boundary and did not dip below the inner wedge of futility. EIT-guided individualized PEEP titration is a novel modality; further well-designed studies are needed to substantiate its utility.
Highlights
Question: Is the EIT-guided PEEP titration in ARDS universally beneficial and effective?
Findings: This systematic review found better survivability, dynamic compliance, in ARDS patients, as the required information size was achieved for a power of 95%. There was no significant improvement in oxygenation and successful weaning incidence compared to conventional methods. However, the required information size for these contexts is yet to be achieved.
Meaning: EIT-guided PEEP titration in ARDS patients showed promising results and warranted further clinical trials.
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Data availability
Data openly available in a public repository & derived data is available on request.
References
Liu S, Tan L, Möller K, et al. Identification of regional overdistension, recruitment and cyclic alveolar collapse with electrical impedance tomography in an experimental ARDS model. Crit Care. 2016;20(1):119. Published 2016 May 3. https://doi.org/10.1186/s13054-016-1300-y.
Franchineau G, Bréchot N, Lebreton G, et al. Bedside contribution of electrical impedance tomography to setting positive end-expiratory pressure for extracorporeal membrane oxygenation-treated patients with severe acute respiratory distress syndrome. Am J Respir Crit Care Med. 2017;196(4):447–57. https://doi.org/10.1164/rccm.201605-1055OC.
Dargaville PA, Rimensberger PC, Frerichs I. Regional tidal ventilation and compliance during a stepwise vital capacity manoeuvre. Intensive Care Med. 2010;36(11):1953–61.
Wolf GK, Gómez-Laberge C, Rettig JS, et al. Mechanical ventilation guided by electrical impedance tomography in experimental acute lung injury. Crit Care Med. 2013;41(5):1296–304. https://doi.org/10.1097/CCM.0b013e3182771516.
Pereira SM, Tucci MR, Morais CCA, et al. Individual positive end-expiratory pressure settings optimize intraoperative mechanical ventilation and reduce postoperative atelectasis. Anesthesiology. 2018;129(6):1070–81. https://doi.org/10.1097/ALN.0000000000002435.
He X, Jiang J, Liu Y, et al. Electrical impedance tomography-guided PEEP Titration in patients undergoing laparoscopic abdominal surgery. Medicine (Baltimore). 2016;95(14): e3306. https://doi.org/10.1097/MD.0000000000003306.
Krause U, Becker K, Hahn G, Dittmar J, Ruschewski W, Paul T. Monitoring of regional lung ventilation using electrical impedance tomography after cardiac surgery in infants and children. Pediatr Cardiol. 2014;35(6):990–7. https://doi.org/10.1007/s00246-014-0886-6.
Liu K, Huang C, Xu M, et al. PEEP guided by electrical impedance tomography during one-lung ventilation in elderly patients undergoing thoracoscopic surgery. Ann Transl Med. 2019;7(23):757. https://doi.org/10.21037/atm.2019.11.95.
Frerichs I, Amato MB, van Kaam AH, et al. Chest electrical impedance tomography examination, data analysis, terminology, clinical use and recommendations: consensus statement of the TRanslational EIT developmeNt stuDy group. Thorax. 2017;72(1):83–93. https://doi.org/10.1136/thoraxjnl-2016-208357.
Costa EL, Borges JB, Melo A, et al. Bedside estimation of recruitable alveolar collapse and hyperdistension by electrical impedance tomography. Intensive Care Med. 2009;35(6):1132–7. https://doi.org/10.1007/s00134-009-1447-y.
Gómez-Laberge C, Arnold JH, Wolf GK. A unified approach for EIT imaging of regional overdistension and atelectasis in acute lung injury. IEEE Trans Med Imaging. 2012;31(3):834–42. https://doi.org/10.1109/TMI.2012.2183641.
Victorino JA, Borges JB, Okamoto VN, et al. Imbalances in regional lung ventilation: a validation study on electrical impedance tomography. Am J Respir Crit Care Med. 2004;169(7):791–800. https://doi.org/10.1164/rccm.200301-133OC.
Constantin JM, Grasso S, Chanques G, et al. Lung morphology predicts response to recruitment maneuver in patients with acute respiratory distress syndrome. Crit Care Med. 2010;38(4):1108–17. https://doi.org/10.1097/CCM.0b013e3181d451ec.
Gattinoni L, Carlesso E, Cressoni M. Selecting the “right” positive end-expiratory pressure level. Curr Opin Crit Care. 2015;21(1):50–7. https://doi.org/10.1097/MCC.0000000000000166.
Costa ELV, Slutsky AS, Brochard LJ, et al. Ventilatory variables and mechanical power in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2021;204(3):303–11. https://doi.org/10.1164/rccm.202009-3467OC.
Chiumello D, Carlesso E, Cadringher P, et al. Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome. Am J Respir Crit Care Med. 2008;178(4):346–55. https://doi.org/10.1164/rccm.200710-1589OC.
Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators, Cavalcanti AB, Suzumura ÉA, et al. Effgect of lung recruitment and titrated Positive End-Expiratory Pressure (PEEP) vs low peep on mortality in patients with acute respiratory distress syndrome: a randomized clinical trial. JAMA. 2017;318(14):1335–1345. https://doi.org/10.1001/jama.2017.14171.
Gattinoni L, Caironi P, Cressoni M, et al. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med. 2006;354(17):1775–86. https://doi.org/10.1056/NEJMoa052052.
Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372(8):747–55. https://doi.org/10.1056/NEJMsa1410639.
Zhao Z, Steinmann D, Frerichs I, Guttmann J, Möller K. PEEP titration guided by ventilation homogeneity: a feasibility study using electrical impedance tomography. Crit Care. 2010;14(1):R8. https://doi.org/10.1186/cc8860.
Erlandsson K, Odenstedt H, Lundin S, Stenqvist O. Positive end-expiratory pressure optimization using electric impedance tomography in morbidly obese patients during laparoscopic gastric bypass surgery. Acta Anaesthesiol Scand. 2006;50(7):833–9. https://doi.org/10.1111/j.1399-6576.2006.01079.x.
Luepschen H, Meier T, Grossherr M, Leibecke T, Karsten J, Leonhardt S. Protective ventilation using electrical impedance tomography. Physiol Meas. 2007;28(7):S247–60. https://doi.org/10.1088/0967-3334/28/7/S18.
Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. Published 2021 Mar 29. https://doi.org/10.1136/bmj.n71.
Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366: l4898.
Sterne JAC, Hernán MA, Reeves BC, Savović J, et al. ROBINS-I: a tool for assessing risk of bias in non-randomized studies of interventions. BMJ. 2016;355: i4919. https://doi.org/10.1136/bmj.i4919.
Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol 2011;64:383–94.
Norris SL, Meerpohl JJ, Akl EA, et al. The skills and experience of GRADE methodologists can be assessed with a simple tool. J Clin Epidemiol. 2016;79:150-158.e1.
Thorlund K, Engstrøm J, Wetterslev J, Brok J, Imberger G, Gluud C. User manual for trial sequential analysis (TSA). Copenhagen Trial Unit, Centre for Clinical Intervention research, Copenhagen, Denmark. 2011:1–115. Available from www.ctu.dk/tsa. Accessed 29 Dec 2023.
Becher T, Buchholz V, Hassel D, et al. Individualization of PEEP and tidal volume in ARDS patients with electrical impedance tomography: a pilot feasibility study. Ann Intensive Care. 2021;11(1):89. Published 2021 Jun 2. https://doi.org/10.1186/s13613-021-00877-7.
He H, Chi Y, Yang Y, et al. Early individualized positive end-expiratory pressure guided by electrical impedance tomography in acute respiratory distress syndrome: a randomized controlled clinical trial. Crit Care. 2021;25(1):230. Published 2021 Jun 30. https://doi.org/10.1186/s13054-021-03645-y.
Hsu HJ, Chang HT, Zhao Z, et al. Positive end-expiratory pressure titration with electrical impedance tomography and pressure-volume curve: a randomized trial in moderate to severe ARDS. Physiol Meas. 2021;42(1):014002. Published 2021 Feb 6. https://doi.org/10.1088/1361-6579/abd679.
Jimenez JV, Munroe E, Weirauch AJ, et al. Electric impedance tomography-guided PEEP titration reduces mechanical power in ARDS: a randomized crossover pilot trial. Crit Care. 2023;27(1):21. Published 2023 Jan 17. https://doi.org/10.1186/s13054-023-04315-x.
Liu X, Liu X, Meng J, et al. Electrical impedance tomography for titration of positive end-expiratory pressure in acute respiratory distress syndrome patients with chronic obstructive pulmonary disease. Crit Care. 2022;26(1):339. Published 2022 Nov 4. https://doi.org/10.1186/s13054-022-04201-y.
Somhorst P, van der Zee P, Endeman H, Gommers D. PEEP-FiO2 table versus EIT to titrate PEEP in mechanically ventilated patients with COVID-19-related ARDS. Crit Care. 2022;26(1):272. Published 2022 Sep 12. https://doi.org/10.1186/s13054-022-04135-5.
Zhao Z, Chang MY, Chang MY, et al. Positive end-expiratory pressure titration with electrical impedance tomography and pressure-volume curve in severe acute respiratory distress syndrome. Ann Intensive Care. 2019;9(1):7. Published 2019 Jan 17. https://doi.org/10.1186/s13613-019-0484-0.
Yu M, Deng Y, Cha J, Jiang L, Wang M, Qiao S, Wang C. PEEP titration by EIT strategies for patients with ARDS: a systematic review and meta-analysis. Med Intensiva (Engl Ed). 2023;47(7):383–90. https://doi.org/10.1016/j.medine.2022.06.020.
Cardinale M, Boussen S, Cungi PJ, et al. Lung-dependent areas collapse, monitored by electrical impedance tomography, may predict the oxygenation response to prone ventilation in COVID-19 acute respiratory distress syndrome. Crit Care Med. 2022;50(7):1093–102. https://doi.org/10.1097/CCM.0000000000005487.
Jonkman AH, Alcala GC, Pavlovsky B, et al. Lung Recruitment Assessed by Electrical Impedance Tomography (RECRUIT): a multicenter study of COVID-19 acute respiratory distress syndrome. Am J Respir Crit Care Med. 2023;208(1):25–38. https://doi.org/10.1164/rccm.202212-2300OC.
Heines SJH, Strauch U, van de Poll MCG, Roekaerts PMHJ, Bergmans DCJJ. Clinical implementation of electric impedance tomography in the treatment of ARDS: a single centre experience. J Clin Monit Comput. 2019;33(2):291–300. https://doi.org/10.1007/s10877-018-0164-x.
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Dr Soumya Sarkar (SS): Search strategy, Study selection, Data extraction, Data synthesis, Risk of bias assessment, quality of the evidence assessment, Manuscript drafting and editing. Dr Bharat Yalla (BY): Search strategy, Study selection, Data extraction. Dr Puneet Khanna (PK): Conceptualization, study selection, Risk of bias assessment, quality of the evidence assessment and editing. Dr Madhurjya Baishya (MB): Risk of bias assessment, quality of the evidence assessment.
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Sarkar, S., Yalla, B., Khanna, P. et al. Is EIT-guided positive end-expiratory pressure titration for optimizing PEEP in ARDS the white elephant in the room? A systematic review with meta-analysis and trial sequential analysis. J Clin Monit Comput (2024). https://doi.org/10.1007/s10877-024-01158-x
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DOI: https://doi.org/10.1007/s10877-024-01158-x