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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LUNG SAFE, unpublished data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Mauri T, Bellani G, unpublished data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