Feasibility of titrating PEEP to minimum elastance for mechanically ventilated patients

Yeong Shiong Chiew, Christopher G Pretty, Geoffrey M Shaw, Yeong Woei Chiew, Bernard Lambermont, Thomas Desaive, J Geoffrey Chase

Selecting positive end-expiratory pressure (PEEP) during mechanical ventilation is important, as it can influence disease progression and outcome of acute respiratory distress syndrome (ARDS) patients. However, there are no well-established methods for optimizing PEEP selection due to the heterogeneity of ARDS. This research investigates the viability of titrating PEEP to minimum elastance for mechanically ventilated ARDS patients. Ten mechanically ventilated ARDS patients from the Christchurch Hospital Intensive Care Unit were included in this study. Each patient underwent a stepwise PEEP recruitment manoeuvre. Airway pressure and flow data were recorded using a pneumotachometer. Patient-specific respiratory elastance (Ers ) and dynamic functional residual capacity (dFRC) at each PEEP level were calculated and compared. Optimal PEEP for each patient was identified by finding the minima of the PEEP-Ers profile. Median Ers and dFRC over all patients and PEEP values were 32.2 cmH2O/l [interquartile range (IQR) 25.0-45.9] and 0.42 l [IQR 0.11-0.87]. These wide ranges reflect patient heterogeneity and variable response to PEEP. The level of PEEP associated with minimum Ers corresponds to a high change of functional residual capacity, representing the balance between recruitment and minimizing the risk of overdistension. Monitoring patient-specific Ers can provide clinical insight to patient-specific condition and response to PEEP settings. The level of PEEP associated with minimum-Ers can be identified for each patient using a stepwise PEEP recruitment manoeuvre. This 'minimum elastance PEEP' may represent a patient-specific optimal setting during mechanical ventilation. Australian New Zealand Clinical Trials Registry: ACTRN12611001179921.