The Effect of Transpulmonary Pressure-Guided Positive End-Expiratory Pressure Titration on Pulmonary Arterial Compliance in Acute Respiratory Distress Syndrome Patients: A Single-Center, Randomized Controlled Pilot Pathophysiological Study.

Abstract

Objectives: To compare the function of positive end-expiratory pressure (PEEP) titration guided by transpulmonary pressure (Ptp) with traditional lung-protective ventilation to optimize pulmonary arterial compliance (Cpa) in acute respiratory distress syndrome (ARDS) patients.

Design: A single center, randomized controlled pilot pathophysiological study.

Setting: A respiratory ICU in China.

Patients/subjects: Adult patients diagnosed with ARDS who had received invasive mechanical ventilation for less than 72 hours.

Interventions: Patients were randomized to the Ptp group or empirical low tidal volume lung-protective group.

Measurements and main results: The primary endpoint was the difference in the Cpa dynamic changes between the two groups during the first 72 hours of intervention following enrollment. A total of 40 patients were included in the study, with 20 patients in the Ptp group and 20 patients in the control group. The Cpa in the Ptp group was 3.98 ± 0.46 mL/mm Hg at randomization, which was not significantly different from that in the control group (3.89 ± 0.40 mL/mm Hg). The Cpa in the Ptp group was significantly higher than that in the control group (p = 0.039) during the 72 hours of dynamic monitoring performed after enrollment. However, Cpa did not change significantly over time, and there was no significant difference in the trend between the two groups. There was a significant difference in the dynamic change of the right ventricular ejection fraction and oxygen delivery index between the two groups within 72 hours after randomization (p < 0.05). The change in the right ventricular end-diastolic transverse diameter/left ventricular end-diastolic transverse diameter ratio and in the tricuspid annular plane systolic excursion was significantly different between the two groups (p < 0.05).

Conclusions: Ptp-guided PEEP titration was superior to traditional lung-protective ventilation in maintaining a higher Cpa and preserving right ventricular function in patients with moderate-to-severe ARDS caused by pneumonia.