Computed tomography assessment of PEEP-induced alveolar recruitment in patients with severe COVID-19 pneumonia

Critical Care

Denise Battaglini¹  Chiara Robba¹  Iole Brunetti¹  Maurizio Cereda²  Jacob Herrmann³  Sarah E. Gerard⁴  Yi Xin⁵  Lorenzo Maiello⁶  Nicolò Patroniti⁷  Paolo Pelosi⁷  Lorenzo Ball⁷  Antonio Vena⁸  Daniele Roberto Giacobbe⁸  Matteo Bassetti⁹  Patricia R. M. Rocco^1,10  Sara Seitun^1,11  Giuseppe Minetti^1,11  Lucio Castellan^1,11 

[1] Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS Per L’Oncologia e le Neuroscienze, Genoa, Italy;Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Department of Biomedical Engineering, Harvard Medical School, Boston, MA, USA;Department of Radiology, Harvard Medical School, Boston, MA, USA;Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy;Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy;Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS Per L’Oncologia e le Neuroscienze, Genoa, Italy;Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS Per L’Oncologia e le Neuroscienze, Genoa, Italy;Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS Per L’Oncologia e le Neuroscienze, Genoa, Italy;Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy;Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil;Radiology Department, Ospedale Policlinico San Martino, IRCCS Per L’Oncologia e le Neuroscienze, Genoa, Italy;

关键词: COVID-19;    ARDS;    Respiratory system mechanics;    Mechanical ventilation;    CT scan;   

DOI  :  10.1186/s13054-021-03477-w

来源: Springer

【 摘 要 】

BackgroundThere is a paucity of data concerning the optimal ventilator management in patients with COVID-19 pneumonia; particularly, the optimal levels of positive-end expiratory pressure (PEEP) are unknown. We aimed to investigate the effects of two levels of PEEP on alveolar recruitment in critically ill patients with severe COVID-19 pneumonia.MethodsA single-center cohort study was conducted in a 39-bed intensive care unit at a university-affiliated hospital in Genoa, Italy. Chest computed tomography (CT) was performed to quantify aeration at 8 and 16 cmH2O PEEP. The primary endpoint was the amount of alveolar recruitment, defined as the change in the non-aerated compartment at the two PEEP levels on CT scan.ResultsForty-two patients were included in this analysis. Alveolar recruitment was median [interquartile range] 2.7 [0.7–4.5] % of lung weight and was not associated with excess lung weight, PaO2/FiO2 ratio, respiratory system compliance, inflammatory and thrombophilia markers. Patients in the upper quartile of recruitment (recruiters), compared to non-recruiters, had comparable clinical characteristics, lung weight and gas volume. Alveolar recruitment was not different in patients with lower versus higher respiratory system compliance. In a subgroup of 20 patients with available gas exchange data, increasing PEEP decreased respiratory system compliance (median difference, MD − 9 ml/cmH2O, 95% CI from − 12 to − 6 ml/cmH2O, p < 0.001) and the ventilatory ratio (MD − 0.1, 95% CI from − 0.3 to − 0.1, p = 0.003), increased PaO2 with FiO2 = 0.5 (MD 24 mmHg, 95% CI from 12 to 51 mmHg, p < 0.001), but did not change PaO2 with FiO2 = 1.0 (MD 7 mmHg, 95% CI from − 12 to 49 mmHg, p = 0.313). Moreover, alveolar recruitment was not correlated with improvement of oxygenation or venous admixture.ConclusionsIn patients with severe COVID-19 pneumonia, higher PEEP resulted in limited alveolar recruitment. These findings suggest limiting PEEP strictly to the values necessary to maintain oxygenation, thus avoiding the use of higher PEEP levels.

【 授权许可】

CC BY