CHEST Guidelines-Role-of-High-Positive-End-Expiratory-Pressure-in-P

Role-of-High-Positive-End-Expiratory-Pressure-in-P

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This letter to the editor addresses a recent study on the effects of high positive end-expiratory pressure (PEEP) on patients with Acute Respiratory Distress Syndrome (ARDS), as published in the journal CHEST. Dr. Ajay Kumar Jha offers critique and suggestions aimed at enhancing the understanding of mechanical ventilation effects, especially in patients exhibiting intense inspiratory efforts.<br /><br />Dr. Jha highlights that intense inspiratory efforts or variations in esophageal pressure often result in higher tidal volumes (TV) during ventilation. He suggests that more detailed mechanistic data could help estimate inspiratory effort impacts on patients. According to Jha, while high PEEP can theoretically reduce lung strain by decreasing TV, it can sometimes lead to increased TV in some patients, thereby not effectively reducing lung stress unless there's a corresponding rise in functional residual capacity.<br /><br />Jha points out that the study shows similar driving pressure and transpulmonary pressure at both low and high PEEP levels, yet TV often decreases due to a significant drop in respiratory system compliance (CRS). He recommends that better patient outcome data could have been obtained by closely monitoring CRS and TV changes aligned with PEEP adjustments, to provide more insights into patient responses.<br /><br />Furthermore, he notes the role of CO2 partial pressure in potentially tempering high PEEP effects and suggests that cardiac output and blood pressure effects at varying PEEP levels need more focused analysis, especially in patients with compliant lungs.<br /><br />Overall, Dr. Jha calls for simultaneous monitoring of multiple respiratory parameters to improve therapeutic management of ARDS, suggesting that stratifying patients based on CRS or TV improvements could yield additional understanding.

Keywords

PEEP

ARDS

mechanical ventilation

inspiratory efforts

tidal volumes

lung strain

respiratory compliance

transpulmonary pressure

CO2 partial pressure

therapeutic management