Jesse Liou, MD
Physician
Christiana Care Health System
Newark, Delaware
Disclosure information not submitted.
Daniel Doherty, MD
Physician
Christiana Care Health System, United States
Disclosure information not submitted.
Tom Gillin, BS, RRT, BS RRT
Respiratory Therapist
Christiana Care Health System, United States
Disclosure information not submitted.
John Emberger, BS, RRT, FAARC
Respiratory Therapist
Christiana Care Health System, United States
Disclosure information not submitted.
Yeonjoo Yi, PhD
Biostatistician
Christiana Care Health System, United States
Disclosure information not submitted.
Luis Cardenas, DO, PhD
Medical Director, Surgical Critical Care; PD, SCC Fellowship
Christiana Care Health System
Newark, Delaware
Disclosure information not submitted.
Michael Benninghoff, DO, MS
Physician
Christiana Care Health System, United States
Disclosure information not submitted.
Michael Vest, DO
Physician
Christiana Care Health System, United States
Disclosure information not submitted.
Andrew Deitchman, MD
Physician
Christiana Care Hospital, United States
Disclosure information not submitted.
Title: Transpulmonary Pressure Guided Peep Titration for Mechanical Ventilation in the Obese
Introduction: Obesity complicates optimal ventilator management by increasing transmitted intrathoracic pressures onto the lungs leading to atelectasis. It is well known that the measured plateau pressure (PPLAT) may not be reflective of true alveolar distending pressures in obese patients. Individualizing care in this population using transpulmonary pressures (PL) obtained by esophageal manometry to optimize positive end-expiratory pressure (PEEP) may be more lung protective. We sought to describe changes in oxygenation and pulmonary mechanics with implementation of a protocol for titration of PEEP based on P<sub>L in obese patients.
Methods: We conducted a retrospective study of adult patients (>18 years) with class II and III obesity (BMI ≥ 35 kg/m2) undergoing mechanical ventilation with esophageal manometry to guide ventilator management. The decision to use the protocol was at the discretion of the treating clinicians. Exclusion criteria for our protocol includes esophageal varices, tumors, ulcers, recent surgery, or platelets < 10,000). P<sub>L is calculated by (airway pressure – pleural pressure, as estimated via esophageal manometry). PEEP is titrated for an End Expiratory (Exp) P<sub>L of 0 ± 2 and an End Inspiratory (Insp) P<sub>L < 20. Primary outcomes of this study were the changes in PEEP, fraction of inspired oxygenation (FiO2), SpO2/FiO2 ratio (S:F), driving pressure (DP) after P<sub>L guided PEEP titration at 4 hours (h) and 24h.
Results: Thirty-one patients were included in the study. Average age was 54 and BMI was 47.73. The median Insp P<sub>L was 8.54. No patients had Insp P<sub>L >14. The median Exp P<sub>L was -3.26. Median P<sub>PLAT was 33cmH2O after 4h and 31cmH2O after 24h. After 4h, median PEEP increased from 12cmH2O to 20cmH2O (p< 0.0001) with a corresponding decrease in median DP from 15cmH2O to 13cmH2O (p=0.0005). Additionally at 4h, oxygenation improved as median FiO2 decreased from 0.8 to 0.55 (p< 0.0001) and median S:F improved from 120 to 176.35 (p< 0.0001). Furthermore, improvements in oxygenation continued at 24h, with a median S:F of 218.
Conclusions: PL guided PEEP in class II and III obesity resulted in higher PEEP, lower DP, and lead to improved oxygenation as reflected by lower FiO2 and higher S:F.