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Bedside PEEP Setting by EIT

Giacomo Bellani, MD, PhD

University of Milan-Bicocca

A.O. San Gerardo

Monza (Italy)

@Gicobellani

INSTITUTIONAL: Research grants from:

– Draeger

– Maquet

Patent transferal to: Draeger

PERSONAL

Consultancy fee from: Draeger, Dimar

Lecturing fees: Draeger, GE, Pfizer

Co-owner and president of ReviewerCredits.com

Conflicts of Interest

Current status of «PEEP setting»

Parameter Mild

(n=722;

30%)

Moderate

(n=1110;

46%)

Severe

(n=564;

24%)

P value 1

Set PEEP

(cmH2O)

7.4±2.7 8.3±3.2 10.1±3.7 <0.001

Bellani, Laffey et al. JAMA 2016

And «PEEP titration»

Parameter Mild

(n=722;

30%)

Moderate

(n=1110;

46%)

Severe

(n=564;

24%)

P value 1

DAY 1

Set PEEP

(cmH2O)7 [5-10] 8 [5.00-10.00] 10 [8-12] <0.001

FiO2 0.4 [0.4-0.5] 0.6 [0.5-0.7] 1 [0.8-1] <0.001

DAY 2

Set PEEP

(cmH2O)6 [5-8] 8 [6-10] 10 [8-12] <0.001

FiO2 0.4 [0.35-0.50] 0.5 [0.40-0.60] 0.7 [0.5-0.9] <0.001

LUNG SAFE, unpublished data

Moderate/severe ARDS Mild ARDS

CAN WE USE EIT TO TITRATE PEEP AT BEDSIDE?

PEEP + 2cmH2O

EIT and PEEP change

DEELV

Recruitment

Alveolardistension

PEEP + 2cmH2O

DEELV=Rec+Crs*DPEEP

DPEEP= 5 cmH2O

Paw [cmH2O]

%

Opening and closing pressures

0 5 10 15 20 25 30 35 40 45 500

10

20

30

40

50

Openingpressure

Closingpressure

Crotti et Al. Am J resp. Crit care 2001

ISO-PEEP

recruitmentmanouver

recruitmentmanouver

PEEP + 2cmH2O

Setting PEEP by means of EIT

25’

Setting PEEP by means of EIT

NIH TABLE EIT

PEEP-NIH

PEEP-EIT

PEEP-EIT+2RM RM RM

Primary endpoint:FeasibilitySecondary endpoints:PEEP levelOxygenationEIT derived data

Up to

18 cmH2O

>10% drop

Feasible in 14/16 patients (87%)PEEPEITvs PEEPNIH 13 ± 3 vs. 9 ± 2 cmH2OMean number of changes 2 ± 1

Recruitment is not associated with oxygenation improvement

Courtesy of G. Foti

Courtesy of G. Foti

Would you paralyze this patient?

Mauri T, Bellani G, unpublished data

Would you paralyze this patient?

Conclusion

Tool to individualise PEEP at the beedsideare needed

Lung Heterogeneity should be taken intoaccount

EIT is a promising tool

Impact on patients’ outcome has to be shown