Utilizing Indirect Intrapleural Pressure to Guide Mechanical Ventilation in Burn Patients with ARDS.

Abstract

Patients with severe burn injuries are at risk of developing acute respiratory distress syndrome (ARDS). Modern ARDS management does not typically factor in how burn injury influences lung dynamics during ventilator management. Obtaining indirect intrapleural pressures via esophageal pressure monitoring (Pes) may provide unique guidance on optimal positive end expiratory pressure (PEEP) titration to prevent alveolar collapse while ensuring safe plateau pressures but is not well described in burn injured patients. This work examined the use of Pes in burn injured patients with ARDS to determine its effect on ventilator changes. Burn injured patients admitted to an ABA verified burn center who developed ARDS by the Berlin definition and received Pes were retrospectively reviewed to determine ventilator settings and oxygenation trends. Severity of ARDS and oxygenation were determined by PaO2 to FiO2 (P/F) ratios and oxygenation indices (OI) prior to Pes use, and at 1-, 3- and 5-day intervals following initiation. Of the 23 patients included, the median revised Baux score was 91.6 (73.9-114.6), and the mortality rate was 82.6%. Increases in PEEP were required [12 (4) vs 17 (4); p<.0001] following Pes initiation. P/F ratios increased by day 5 post-Pes monitoring [300 (35.1)] compared to pre- [141 (26.5); p=.0020], 1 day post- [169 (26.5); p=.0134] and 3 days post- [179 (29.4); p=.0325] monitoring. OI between pre-Pes monitoring and day 5 post Pes monitoring, were not significant [17.3 (1.92) vs 13.4 (2.57)]. A strategy incorporating Pes to guide ventilator management in burn injured patients with ARDS may be used.