Positive end-expiratory pressure titrated according to respiratory system mechanics or to ARDSNetwork table did not guarantee positive end-expiratory transpulmonary pressure in acute respiratory distress syndrome

Purpose: Pulmonary recruitment and positive end-expiratory pressure (PEEP) titrated according to minimal static elastance of the respiratory system (PEEP Estat,RS ) compared to PEEP set according to the ARDSNetwork table (PEEP ARDSNetwork ) as a strategy to prevent ventilator-associated lung injury (VALI) in patients with acute respiratory distress syndrome (ARDS) increases mortality. Alternatively, avoiding negative end-expiratory transpulmonary pressure has been discussed as superior PEEP titration strategy. Therefore, we tested whether PEEP Estat,RS or PEEP ARDSNetwork prevent negative end-expiratory transpulmonary pressure in ARDS patients. Material and methods: Thirteen patients with moderate to severe ARDS were studied at PEEP ARDSNetwork versus PEEP Estat,RS . Patients were then grouped post hoc according to the end-expiratory transpulmonary pressure (positive or negative). Results: 7 out of 13 patients showed negative end-expiratory transpulmonary pressures (Ptp−) with both strategies (PEEP ARDSNetwork : - 5.4 ± 3.5 vs. 2.2 ± 3.7 cm H 2 O, p =.005; PEEP Estat,RS : - 3.6 ± 1.5 vs. 3.5 ± 3.3 cm H 2 O, p <.001). Ptp− was associated with higher intra-abdominal pressure and lower end-expiratory lung volume with both PEEP strategies. Conclusions: In patients with moderate-to-severe ARDS, PEEP titrated according to the minimal static elastance of the respiratory system or according to the ARDSNetwork table did not prevent negative end-expiratory transpulmonary pressure.