TY - JOUR
T1 - Recruitment-to-inflation ratio for bedside PEEP selection in acute respiratory distress syndrome
AU - Rosà, Tommaso
AU - Bongiovanni, Filippo
AU - Michi, Teresa
AU - Mastropietro, Claudia
AU - Menga, Luca Salvatore
AU - De Pascale, Gennaro
AU - Antonelli, Massimo
AU - Grieco, Domenico Luca
PY - 2024
Y1 - 2024
N2 - In acute respiratory distress syndrome, the role of positive end-expiratory pressure (PEEP) to prevent ventilator-induced lung injury is controversial. Randomized trials comparing higher versus lower PEEP strategies failed to demonstrate a clinical benefit. This may depend on the inter-individually variable potential for lung recruitment (i.e. recruitability), which would warrant PEEP individualization to balance alveolar recruitment and the unavoidable baby lung overinflation produced by high pressure. Many techniques have been used to assess recruitability, including lung imaging, multiple pressure-volume curves and lung volume measurement. The Recruitment-to-Inflation ratio (R/I) has been recently proposed to bedside assess recruitability without additional equipment. R/I assessment is a simplified technique based on the multiple pressure-volume curve concept: it is measured by monitoring respiratory mechanics and exhaled tidal volume during a 10-cmH(2)O one-breath derecruitment maneuver after a short high-PEEP test. R/I scales recruited volume to respiratory system compliance, and normalizes recruitment to a proxy of actual lung size. With modest R/I (<0.3-0.4), setting low PEEP (5-8 cmH(2)O) may be advisable; with R/I>0.6-0.7, high PEEP (>15 cmH(2)O) can be considered, provided that airway and/or transpulmonary plateau pressure do not exceed safety limits. In case of intermediate R/I (approximate to 0.5), a more granular assessment of recruitability may be needed. This could be accomplished with advanced monitoring tools, like sequential lung volume measurement with granular R/I assessment or electrical impedance tomography monitoring during a decremental PEEP trial. In this review, we discuss R/I rationale, applications and limits, providing insights on its clinical use for PEEP selection in moderate-to-severe acute respiratory distress syndrome.
AB - In acute respiratory distress syndrome, the role of positive end-expiratory pressure (PEEP) to prevent ventilator-induced lung injury is controversial. Randomized trials comparing higher versus lower PEEP strategies failed to demonstrate a clinical benefit. This may depend on the inter-individually variable potential for lung recruitment (i.e. recruitability), which would warrant PEEP individualization to balance alveolar recruitment and the unavoidable baby lung overinflation produced by high pressure. Many techniques have been used to assess recruitability, including lung imaging, multiple pressure-volume curves and lung volume measurement. The Recruitment-to-Inflation ratio (R/I) has been recently proposed to bedside assess recruitability without additional equipment. R/I assessment is a simplified technique based on the multiple pressure-volume curve concept: it is measured by monitoring respiratory mechanics and exhaled tidal volume during a 10-cmH(2)O one-breath derecruitment maneuver after a short high-PEEP test. R/I scales recruited volume to respiratory system compliance, and normalizes recruitment to a proxy of actual lung size. With modest R/I (<0.3-0.4), setting low PEEP (5-8 cmH(2)O) may be advisable; with R/I>0.6-0.7, high PEEP (>15 cmH(2)O) can be considered, provided that airway and/or transpulmonary plateau pressure do not exceed safety limits. In case of intermediate R/I (approximate to 0.5), a more granular assessment of recruitability may be needed. This could be accomplished with advanced monitoring tools, like sequential lung volume measurement with granular R/I assessment or electrical impedance tomography monitoring during a decremental PEEP trial. In this review, we discuss R/I rationale, applications and limits, providing insights on its clinical use for PEEP selection in moderate-to-severe acute respiratory distress syndrome.
KW - Positive pressure respiration
KW - Respiratory distress syndrome
KW - Respiratory mechanics
KW - Ventilator-induced lung injury
KW - Positive pressure respiration
KW - Respiratory distress syndrome
KW - Respiratory mechanics
KW - Ventilator-induced lung injury
UR - http://hdl.handle.net/10807/297454
U2 - 10.23736/s0375-9393.24.17982-5
DO - 10.23736/s0375-9393.24.17982-5
M3 - Article
SN - 0375-9393
VL - 90
SP - 694
EP - 706
JO - Minerva Anestesiologica
JF - Minerva Anestesiologica
ER -