Transpulmonary Pressure as a Predictor of Successful Lung Recruitment: Reanalysis of a Multicenter International Randomized Clinical Trial.

Autor: Santarisi A; Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. asantari@bidmc.harvard.edu.; Center for Anesthesia Research Excellence, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts., Suleiman A; Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.; Center for Anesthesia Research Excellence, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.; Department of Anesthesia and Intensive Care, Faculty of Medicine, University of Jordan, Amman, Jordan., Redaelli S; Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.; Center for Anesthesia Research Excellence, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.; School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy., von Wedel D; Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.; Center for Anesthesia Research Excellence, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts., Beitler JR; Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, New York., Talmor D; Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts., Goodspeed V; Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.; Center for Anesthesia Research Excellence, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts., Jung B; Center for Anesthesia Research Excellence, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.; Medical Intensive Care Unit, Montpellier University, Montpellier, France.; Department of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts., Schaefer MS; Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.; Center for Anesthesia Research Excellence, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.; Department of Anesthesiology, Düsseldorf University Hospital, Dusseldorf, Germany., Baedorf Kassis E; Center for Anesthesia Research Excellence, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.; Department of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Jazyk: angličtina
Zdroj: Respiratory care [Respir Care] 2024 Oct 08. Date of Electronic Publication: 2024 Oct 08.
DOI: 10.4187/respcare.11736
Abstrakt: Background: Recruitment maneuvers are used in patients with ARDS to enhance oxygenation and lung mechanics. Heterogeneous lung and chest-wall mechanics lead to unpredictable transpulmonary pressures and could impact recruitment maneuver success. Tailoring care based on individualized transpulmonary pressure might optimize recruitment, preventing overdistention. This study aimed to identify the optimal transpulmonary pressure for effective recruitment and to explore its association with baseline characteristics.
Methods: We performed post hoc analysis on the Esophageal Pressure Guided Ventilation (EpVent2) trial. We estimated the dose-response relationship between end-recruitment end-inspiratory transpulmonary pressure and the change in lung elastance after a recruitment maneuver by using logistic regression weighted by a generalized propensity score. A positive change in lung elastance was indicative of overdistention. We examined how patient characteristics, disease severity markers, and respiratory parameters predict transpulmonary pressure by using multivariate linear regression models and dominance analyses.
Results: Of 121 subjects, 43.8% had a positive change in lung elastance. Subjects with a positive change in lung elastance had a mean ± SD transpulmonary pressure of 15.1 ± 4.9 cm H 2 O, compared with 13.9 ± 3.9 cm H 2 O in those with a negative change in lung elastance. Higher transpulmonary pressure was associated with increased probability of a positive change in lung elastance (adjusted odds ratio 1.35 per 1 cm H 2 O of transpulmonary pressure, 95% CI 1.13-1.61; P = .001), which indicated an S-shaped dose-response curve, with overdistention probability > 50% at transpulmonary pressure values > 18.3 cm H 2 O. The volume of recruitment was transpulmonary pressure-dependent ( P < .001; R 2 = 0.49) and inversely related to a change in lung elastance after adjusting for baseline lung elastance ( P < .001; R 2 = 0.43). Negative correlations were observed between transpulmonary pressure and body mass index, PEEP, Sequential Organ Failure Assessment score, and P aO 2 /F IO 2 , whereas baseline lung elastance showed a positive correlation. The body mass index emerged as the dominant negative predictor of transpulmonary pressure (ranking 1; contribution to R 2 = 0.08), whereas pre-recruitment elastance was the sole positive predictor (contribution to R 2 = 0.06).
Conclusions: Higher end-recruitment transpulmonary pressure increases the volume of recruitment but raises the risk of overdistention, providing the rationale for transpulmonary pressure to be used as a clinical target. Predictors, for example, body mass index, could guide recruitment maneuver individualization to balance adequate volume gain with overdistention.
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Databáze: MEDLINE
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