{"title":"Comparison of electrical impedance tomography, blood gas analysis, and respiratory mechanics for positive end-expiratory pressure titration","authors":"Han Chen, Takeshi Yoshida, Jian-Xin Zhou","doi":"10.1186/s13054-024-05137-1","DOIUrl":null,"url":null,"abstract":"<p><b>To the Editor</b></p><p>Electrical impedance tomography (EIT) is increasingly utilized for tailoring positive end-expiratory pressure (PEEP). By non-invasively assessing lung collapse and over-distention [1], EIT helps adjust PEEP to minimize both conditions, assuming they are equally harmful. The EIT-guided PEEP selection approach may potentially provide more lung protection by reducing mechanical power [2].</p><p>Although the balance between over-distension and collapse may help individualize PEEP titration, the requirement for specialized EIT equipment limits its widespread application. Furthermore, EIT focuses on morphology without considering PEEP's impact on hemodynamics and ventilation-perfusion matching. Alternatively, PEEP can be titrated by calculating intrapulmonary shunt (Qs/Qt) and dead space (Vd/Vt) using blood gases [3]. High alveolar pressure can cause both lung over-distension (high stress and strain) and pulmonary capillary collapse and subsequently impaired CO<sub>2</sub> elimination (namely functional over-distension). However, whether the calculated Vd/Vt and Qs/Qt are consistent with EIT-derived over-distension and collapse is unclear. In this pilot study, we attempted to compare these PEEP selection approaches.</p><p>The experiment protocol was approved by the Animal Care Committee of Fujian Provincial Hospital. The animals were treated in compliance with the hospital's guidelines for the care and utilization of laboratory animals.</p><h3>Preparation and measurements</h3><p>Eight male Bama miniatured pigs (weight 40.1 to 58.0 kg) were anesthetized with 10 mg·kg<sup>–1</sup>·h<sup>–1</sup> pentobarbital. Rocuronium bromide boluses of 0.5 mg·kg<sup>–1</sup> were administered as needed to suppress spontaneous breathing. After tracheotomy, mechanical ventilation was initiated. A catheter in the right carotid artery enabled blood pressure monitoring and gas sampling. A Swan-Ganz catheter, inserted via the internal jugular vein, facilitated mixed venous blood sampling and hemodynamic measurements. Mixed expired CO<sub>2</sub> (PeCO<sub>2</sub>) was measured via a mainstream PeCO<sub>2</sub> module. Vital signs and cardiac output (via thermodilution) were monitored. Collapse and over-distension were determined using EIT (PulmoVista 500, Dräger, Germany) at the 4th–5th intercostal space, with thresholds previously reported [1].</p><h3>Experiment protocol</h3><p>Lung injury was induced using a 'two-hits' model: surfactant depletion and injurious ventilation [4]. Saline lung lavage (30 ml·kg-1) was repeated until PaO<sub>2</sub>/FiO<sub>2</sub> < 100 mmHg for 10 min at PEEP 5 cmH<sub>2</sub>O, followed by injurious ventilation for 60 min, with driving pressure/PEEP adjusted every 15 min [4].</p><p>After lung recruitment, a decremental PEEP trial (20 to 4 cmH<sub>2</sub>O, 2 cmH<sub>2</sub>O steps) was conducted. Static compliance, cardiac output, and blood gases were measured at each PEEP level. EIT data were continuously recorded for offline analysis. Pigs were euthanized post-experiment with pentobarbital overdose. Qs/Qt and Vd/Vt were calculated using established formulas (5). 'Optimal' PEEPs were determined by three methods: minimal sum of Vd/Vt and Qs/Qt, maximal compliance, and minimal sum of EIT-measured over-distension and collapse. The lower PEEP was selected in case of a tie.</p><p>As PEEP decreased, collapse and Qs/Qt increased in parallel. PaO<sub>2</sub> exhibited a non-linear relationship with PEEP changes and did not correlate strongly with collapse (Fig. 1A). As PEEP was reduced, over-distension decreased, while Vd/Vt increased (Fig. 1B). Lung compliance peaked at PEEP of 16 cmH<sub>2</sub>O, while the sum of collapse and over-distension was minimized at PEEP of 18 cmH<sub>2</sub>O (Fig. 1C). Blood pressure and cardiac output increased following the decrement of PEEP (Fig. 1D). At the individual level, 'Optimal' PEEP values varied among the three approaches. The EIT-guided approach and Vd/Vt + Qs/Qt method based on blood gas analysis showed discrepancies in PEEP values for all animals. However, when comparing the EIT-guided approach with the best compliance method, two animals exhibited identical PEEP values, while differences remained in others (Fig. 1E). End-of-experiment lung pathology showed no differences among animals (Fig. 1F).</p><figure><figcaption><b data-test=\"figure-caption-text\">Fig. 1</b></figcaption><picture><img alt=\"figure 1\" aria-describedby=\"Fig1\" height=\"537\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05137-1/MediaObjects/13054_2024_5137_Fig1_HTML.png\" width=\"685\"/></picture><p>Panel A: Showing the change of intrapulmonary shunt (Qs/Qt), PaO<sub>2</sub>, and collapse (CL) in response to the decrement of positive end-expiratory pressure (PEEP). Intrapulmonary shunt (Qs/Qt) and collapse (CL) were displayed on the left y-axis, while PaO<sub>2</sub> was displayed on the right y-axis. The trend indicates an increase in both Qs/Qt and CL with the decrement of PEEP, and the trend correlated well between Qs/Qt and CL. PaO<sub>2</sub> demonstrated a biphasic response, initially ascending, followed by a subsequent decline. Panel B: Showing the change of arterial CO<sub>2</sub> partial pressure (PaCO<sub>2</sub>), mixed expired CO<sub>2</sub> partial pressure (PeCO<sub>2</sub>), dead space (Vd/Vt), over-distension (OD) in response to the decrement of PEEP. Vd/Vt and OD were displayed on the left y-axis, while PaCO<sub>2</sub> and PeCO<sub>2</sub> were displayed on the right y-axis. As PEEP decreased, the gap between PaCO<sub>2</sub> and PeCO<sub>2</sub> increased, resulting in an increasing Vd/Vt. In contrast, OD decreased following the decrement of PEEP. Panel C: CL and OD were plotted on the same graph, both displayed on the left y-axis, to illustrate the trend of their sum, which exhibited a U-shaped trend. Additionally, Qs/Qt and Vd/Vt were also plotted on the left y-axis. The right y-axis shows the changes in compliance (Crs), which demonstrated an inverse U-shaped trend. Panel D: Cardiac output (CO) and mean arterial pressure (MAP) gradually increased as PEEP decreased. Panel E: 'Optimal' PEEP selected by EIT (minimal sum of CL and OD, <i>circle</i>), minimal Vd/Vt + Qs/Qt (<i>square</i>), and the best Crs (<i>diamond</i>). The selected PEEP levels by the three approaches exhibited notable discrepancies. Panel F: Showing the lung injury scores at the end of the experiment for each animal. For each animal, six non-overlapping fields were collected and averaged. Briefly, hematoxylin and eosin–stained sections were analyzed for neutrophil infiltration, airway epithelial cell damage, interstitial edema, hyaline membrane formation, hemorrhage, and the total lung injury score as the sum of these criteria. Each criterion was scored on a scale of 0–4, where 0 = normal, 1 = minimal change, 2 = mild change, 3 = moderate change, and 4 = severe change. There were no significant differences in lung injury scores among the animals (p = 0.378)</p><span>Full size image</span><svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-chevron-right-small\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></figure><p>In this pilot experiment, we compared blood-gas-based PEEP titration with EIT to balance over-distension and collapse. Qs/Qt effectively evaluated collapsed tissue without EIT. In contrast, dead space was not effective in detecting over-distension. A notable discrepancy existed between PEEP titration approaches.</p><p>Pulmonary gas exchange depends not only on ventilation but also on matching the blood flow. High PEEP affects hemodynamics, lung perfusion, and ventilation-perfusion matching. Blood-gas-analysis-derived over-distension results from both \"true\" and \"functional\" over-distension (5). We found that Qs/Qt + Vd/Vt derived PEEP was occasionally higher than EIT-derived PEEP, contrary to expectations. While individual animals showed variable optimal PEEP values across methods, averaged data indicated a consistent range of 16–18 cmH₂O. This highlights individual heterogeneity, suggesting that averaged data may mask crucial individual differences. These findings underscore the importance of considering multiple parameters and personalizing PEEP settings.</p><p>This study has some limitations. It's a small, non-randomized pilot study. Second, we used the Enghoff formula to calculate dead space, which includes the shunt effect. PEEP can simultaneously affect true dead space and shunt oppositely, while we assumed minimal shunt effect at high PEEP. Additionally, we didn't compare injury degree (histological, biomarkers) from different PEEP approaches.</p><p>In conclusion, morphology-based and blood gas-based approaches yielded different optimal PEEP levels. The impact of these varying approaches on lung injury warrants further study.</p><p>No datasets were generated or analysed during the current study.</p><dl><dt style=\"min-width:50px;\"><dfn>CL:</dfn></dt><dd>\n<p>Collapse</p>\n</dd><dt style=\"min-width:50px;\"><dfn>CO:</dfn></dt><dd>\n<p>Cardiac output</p>\n</dd><dt style=\"min-width:50px;\"><dfn>CO<sub>2</sub> :</dfn></dt><dd>\n<p>Carbon dioxide</p>\n</dd><dt style=\"min-width:50px;\"><dfn>Crs:</dfn></dt><dd>\n<p>Compliance of respiratory system</p>\n</dd><dt style=\"min-width:50px;\"><dfn>EIT:</dfn></dt><dd>\n<p>Electrical impedance tomography</p>\n</dd><dt style=\"min-width:50px;\"><dfn>FiO<sub>2</sub> :</dfn></dt><dd>\n<p>Fraction of inspired oxygen</p>\n</dd><dt style=\"min-width:50px;\"><dfn>MAP:</dfn></dt><dd>\n<p>Mean arterial pressure</p>\n</dd><dt style=\"min-width:50px;\"><dfn>OD:</dfn></dt><dd>\n<p>Over-distension</p>\n</dd><dt style=\"min-width:50px;\"><dfn>PaCO<sub>2</sub> :</dfn></dt><dd>\n<p>Arterial CO<sub>2</sub> partial pressure</p>\n</dd><dt style=\"min-width:50px;\"><dfn>PaO<sub>2</sub> :</dfn></dt><dd>\n<p>Partial pressure of arterial oxygen</p>\n</dd><dt style=\"min-width:50px;\"><dfn>PeCO<sub>2</sub> :</dfn></dt><dd>\n<p>Mixed expired CO<sub>2</sub> partial pressure</p>\n</dd><dt style=\"min-width:50px;\"><dfn>PEEP:</dfn></dt><dd>\n<p>Positive end-expiratory pressure</p>\n</dd><dt style=\"min-width:50px;\"><dfn>Qs/Qt:</dfn></dt><dd>\n<p>Intrapulmonary shunt</p>\n</dd><dt style=\"min-width:50px;\"><dfn>Vd/Vt:</dfn></dt><dd>\n<p>Dead space</p>\n</dd></dl><ol data-track-component=\"outbound reference\" data-track-context=\"references section\"><li data-counter=\"1.\"><p>Costa EL, Borges JB, Melo A, Suarez-Sipmann F, Toufen C Jr, Bohm SH, et al. Bedside estimation of recruitable alveolar collapse and hyperdistension by electrical impedance tomography. Intensive Care Med. 2009;35:1132–7.</p><p>Article PubMed Google Scholar </p></li><li data-counter=\"2.\"><p>Jimenez JV, Munroe E, Weirauch AJ, Fiorino K, Culter CA, Nelson K, et al. Electric impedance tomography-guided PEEP titration reduces mechanical power in ARDS: a randomized crossover pilot trial. Crit Care. 2023;27:21.</p><p>Article PubMed PubMed Central Google Scholar </p></li><li data-counter=\"3.\"><p>Tusman G, Gogniat E, Madorno M, Otero P, Dianti J, Ceballos IF, et al. Effect of PEEP on dead space in an experimental model of ARDS. Respir Care. 2020;65:11–20.</p><p>Article PubMed Google Scholar </p></li><li data-counter=\"4.\"><p>Yoshida T, Engelberts D, Chen H, Li X, Katira BH, Otulakowski G, et al. Prone position minimizes the exacerbation of effort-dependent lung injury: exploring the mechanism in pigs and evaluating injury in rabbits. Anesthesiology. 2022;136:779–91.</p><p>Article CAS PubMed Google Scholar </p></li><li data-counter=\"5.\"><p>Suárez-Sipmann F, Villar J, Ferrando C, Sánchez-Giralt JA, Tusman G. Monitoring expired CO(2) kinetics to individualize lung-protective ventilation in patients with the acute respiratory distress syndrome. Front Physiol. 2021;12:785014.</p><p>Article PubMed PubMed Central Google Scholar </p></li></ol><p>Download references<svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-download-medium\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></p><p>None.</p><p>HC is supported by the Youth Top Talent Project of Fujian Provincial Foal Eagle Program. The funding bodies had no role in the study design, data collection, analysis, interpretation, or manuscript writing.</p><h3>Authors and Affiliations</h3><ol><li><p>Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital Affiliated to Fuzhou University, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Dongjie 134, Gulou District, Fuzhou, Fujian, China</p><p>Han Chen</p></li><li><p>Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan</p><p>Takeshi Yoshida</p></li><li><p>Beijing Shijitan Hospital, Capital Medical University, Beijing, China</p><p>Jian-Xin Zhou</p></li></ol><span>Authors</span><ol><li><span>Han Chen</span>View author publications<p>You can also search for this author in <span>PubMed<span> </span>Google Scholar</span></p></li><li><span>Takeshi Yoshida</span>View author publications<p>You can also search for this author in <span>PubMed<span> </span>Google Scholar</span></p></li><li><span>Jian-Xin Zhou</span>View author publications<p>You can also search for this author in <span>PubMed<span> </span>Google Scholar</span></p></li></ol><h3>Contributions</h3><p>HC, TY, and JXZ conceived and designed the study. HC performed the experiments and data collection. HC and TY performed data analysis and interpretation. HC prepared the initial draft of the manuscript. All authors reviewed, contributed to, and approved the article’s final version. The corresponding author ultimately submitted the manuscript for publication.</p><h3>Corresponding author</h3><p>Correspondence to Han Chen.</p><h3>Ethics approval and consent to participate</h3>\n<p>The experiment protocol was approved by the Animal Care Committee of Fujian Provincial Hospital. The animals were treated in compliance with the hospital's guidelines for the care and utilization of laboratory animals.</p>\n<h3>Consent for publication</h3>\n<p>Not applicable.</p>\n<h3>Competing interests</h3>\n<p>The authors declare no competing interests.</p><h3>Publisher's Note</h3><p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p><p><b>Open Access</b> This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.</p>\n<p>Reprints and permissions</p><img alt=\"Check for updates. 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Comparison of electrical impedance tomography, blood gas analysis, and respiratory mechanics for positive end-expiratory pressure titration. <i>Crit Care</i> <b>28</b>, 341 (2024). https://doi.org/10.1186/s13054-024-05137-1</p><p>Download citation<svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-download-medium\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></p><ul data-test=\"publication-history\"><li><p>Received<span>: </span><span><time datetime=\"2024-09-09\">09 September 2024</time></span></p></li><li><p>Accepted<span>: </span><span><time datetime=\"2024-10-18\">18 October 2024</time></span></p></li><li><p>Published<span>: </span><span><time datetime=\"2024-10-22\">22 October 2024</time></span></p></li><li><p>DOI</abbr><span>: </span><span>https://doi.org/10.1186/s13054-024-05137-1</span></p></li></ul><h3>Share this article</h3><p>Anyone you share the following link with will be able to read this content:</p><button data-track=\"click\" data-track-action=\"get shareable link\" data-track-external=\"\" data-track-label=\"button\" type=\"button\">Get shareable link</button><p>Sorry, a shareable link is not currently available for this article.</p><p data-track=\"click\" data-track-action=\"select share url\" data-track-label=\"button\"></p><button data-track=\"click\" data-track-action=\"copy share url\" data-track-external=\"\" data-track-label=\"button\" type=\"button\">Copy to clipboard</button><p> Provided by the Springer Nature SharedIt content-sharing initiative </p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":8.8000,"publicationDate":"2024-10-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Critical Care","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1186/s13054-024-05137-1","RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"CRITICAL CARE MEDICINE","Score":null,"Total":0}
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Abstract
To the Editor
Electrical impedance tomography (EIT) is increasingly utilized for tailoring positive end-expiratory pressure (PEEP). By non-invasively assessing lung collapse and over-distention [1], EIT helps adjust PEEP to minimize both conditions, assuming they are equally harmful. The EIT-guided PEEP selection approach may potentially provide more lung protection by reducing mechanical power [2].
Although the balance between over-distension and collapse may help individualize PEEP titration, the requirement for specialized EIT equipment limits its widespread application. Furthermore, EIT focuses on morphology without considering PEEP's impact on hemodynamics and ventilation-perfusion matching. Alternatively, PEEP can be titrated by calculating intrapulmonary shunt (Qs/Qt) and dead space (Vd/Vt) using blood gases [3]. High alveolar pressure can cause both lung over-distension (high stress and strain) and pulmonary capillary collapse and subsequently impaired CO2 elimination (namely functional over-distension). However, whether the calculated Vd/Vt and Qs/Qt are consistent with EIT-derived over-distension and collapse is unclear. In this pilot study, we attempted to compare these PEEP selection approaches.
The experiment protocol was approved by the Animal Care Committee of Fujian Provincial Hospital. The animals were treated in compliance with the hospital's guidelines for the care and utilization of laboratory animals.
Preparation and measurements
Eight male Bama miniatured pigs (weight 40.1 to 58.0 kg) were anesthetized with 10 mg·kg–1·h–1 pentobarbital. Rocuronium bromide boluses of 0.5 mg·kg–1 were administered as needed to suppress spontaneous breathing. After tracheotomy, mechanical ventilation was initiated. A catheter in the right carotid artery enabled blood pressure monitoring and gas sampling. A Swan-Ganz catheter, inserted via the internal jugular vein, facilitated mixed venous blood sampling and hemodynamic measurements. Mixed expired CO2 (PeCO2) was measured via a mainstream PeCO2 module. Vital signs and cardiac output (via thermodilution) were monitored. Collapse and over-distension were determined using EIT (PulmoVista 500, Dräger, Germany) at the 4th–5th intercostal space, with thresholds previously reported [1].
Experiment protocol
Lung injury was induced using a 'two-hits' model: surfactant depletion and injurious ventilation [4]. Saline lung lavage (30 ml·kg-1) was repeated until PaO2/FiO2 < 100 mmHg for 10 min at PEEP 5 cmH2O, followed by injurious ventilation for 60 min, with driving pressure/PEEP adjusted every 15 min [4].
After lung recruitment, a decremental PEEP trial (20 to 4 cmH2O, 2 cmH2O steps) was conducted. Static compliance, cardiac output, and blood gases were measured at each PEEP level. EIT data were continuously recorded for offline analysis. Pigs were euthanized post-experiment with pentobarbital overdose. Qs/Qt and Vd/Vt were calculated using established formulas (5). 'Optimal' PEEPs were determined by three methods: minimal sum of Vd/Vt and Qs/Qt, maximal compliance, and minimal sum of EIT-measured over-distension and collapse. The lower PEEP was selected in case of a tie.
As PEEP decreased, collapse and Qs/Qt increased in parallel. PaO2 exhibited a non-linear relationship with PEEP changes and did not correlate strongly with collapse (Fig. 1A). As PEEP was reduced, over-distension decreased, while Vd/Vt increased (Fig. 1B). Lung compliance peaked at PEEP of 16 cmH2O, while the sum of collapse and over-distension was minimized at PEEP of 18 cmH2O (Fig. 1C). Blood pressure and cardiac output increased following the decrement of PEEP (Fig. 1D). At the individual level, 'Optimal' PEEP values varied among the three approaches. The EIT-guided approach and Vd/Vt + Qs/Qt method based on blood gas analysis showed discrepancies in PEEP values for all animals. However, when comparing the EIT-guided approach with the best compliance method, two animals exhibited identical PEEP values, while differences remained in others (Fig. 1E). End-of-experiment lung pathology showed no differences among animals (Fig. 1F).
In this pilot experiment, we compared blood-gas-based PEEP titration with EIT to balance over-distension and collapse. Qs/Qt effectively evaluated collapsed tissue without EIT. In contrast, dead space was not effective in detecting over-distension. A notable discrepancy existed between PEEP titration approaches.
Pulmonary gas exchange depends not only on ventilation but also on matching the blood flow. High PEEP affects hemodynamics, lung perfusion, and ventilation-perfusion matching. Blood-gas-analysis-derived over-distension results from both "true" and "functional" over-distension (5). We found that Qs/Qt + Vd/Vt derived PEEP was occasionally higher than EIT-derived PEEP, contrary to expectations. While individual animals showed variable optimal PEEP values across methods, averaged data indicated a consistent range of 16–18 cmH₂O. This highlights individual heterogeneity, suggesting that averaged data may mask crucial individual differences. These findings underscore the importance of considering multiple parameters and personalizing PEEP settings.
This study has some limitations. It's a small, non-randomized pilot study. Second, we used the Enghoff formula to calculate dead space, which includes the shunt effect. PEEP can simultaneously affect true dead space and shunt oppositely, while we assumed minimal shunt effect at high PEEP. Additionally, we didn't compare injury degree (histological, biomarkers) from different PEEP approaches.
In conclusion, morphology-based and blood gas-based approaches yielded different optimal PEEP levels. The impact of these varying approaches on lung injury warrants further study.
No datasets were generated or analysed during the current study.
CL:
Collapse
CO:
Cardiac output
CO2 :
Carbon dioxide
Crs:
Compliance of respiratory system
EIT:
Electrical impedance tomography
FiO2 :
Fraction of inspired oxygen
MAP:
Mean arterial pressure
OD:
Over-distension
PaCO2 :
Arterial CO2 partial pressure
PaO2 :
Partial pressure of arterial oxygen
PeCO2 :
Mixed expired CO2 partial pressure
PEEP:
Positive end-expiratory pressure
Qs/Qt:
Intrapulmonary shunt
Vd/Vt:
Dead space
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HC is supported by the Youth Top Talent Project of Fujian Provincial Foal Eagle Program. The funding bodies had no role in the study design, data collection, analysis, interpretation, or manuscript writing.
Authors and Affiliations
Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital Affiliated to Fuzhou University, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Dongjie 134, Gulou District, Fuzhou, Fujian, China
Han Chen
Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
Takeshi Yoshida
Beijing Shijitan Hospital, Capital Medical University, Beijing, China
Jian-Xin Zhou
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Contributions
HC, TY, and JXZ conceived and designed the study. HC performed the experiments and data collection. HC and TY performed data analysis and interpretation. HC prepared the initial draft of the manuscript. All authors reviewed, contributed to, and approved the article’s final version. The corresponding author ultimately submitted the manuscript for publication.
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Correspondence to Han Chen.
Ethics approval and consent to participate
The experiment protocol was approved by the Animal Care Committee of Fujian Provincial Hospital. The animals were treated in compliance with the hospital's guidelines for the care and utilization of laboratory animals.
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The authors declare no competing interests.
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Chen, H., Yoshida, T. & Zhou, JX. Comparison of electrical impedance tomography, blood gas analysis, and respiratory mechanics for positive end-expiratory pressure titration. Crit Care28, 341 (2024). https://doi.org/10.1186/s13054-024-05137-1
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Critical Care is an esteemed international medical journal that undergoes a rigorous peer-review process to maintain its high quality standards. Its primary objective is to enhance the healthcare services offered to critically ill patients. To achieve this, the journal focuses on gathering, exchanging, disseminating, and endorsing evidence-based information that is highly relevant to intensivists. By doing so, Critical Care seeks to provide a thorough and inclusive examination of the intensive care field.