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Comment & Response
August 13, 2019

Strategies to Adjust Positive End-Expiratory Pressure in Patients With ARDS

Author Affiliations
  • 1Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
  • 2Hedenstierna Laboratory, Uppsala University, Uppsala, Sweden
JAMA. 2019;322(6):581. doi:10.1001/jama.2019.7884

To the Editor In the EPVent-2 study of patients with ARDS,1 PEEP in the PES-guided group was titrated based on the assumption that end-expiratory PES is directly representative of pleural pressure and that positive end-expiratory PES with concomitant negative PL indicates that the chest wall causes collapse of alveoli at end expiration. To prevent this assumed collapse, PEEP was increased until PL was zero or above according to an empirical PL − Fio2 table. The level of end-expiratory PES is thus a measure of the assumed negative effect of the chest wall on the lung. During the first week, there was an overall improvement in the condition of the patients with increasing Pao2:Fio2 ratio and a 6–cm H2O lower PEEP than at day 1. However, end-expiratory PES remained within approximately 1 cm H2O of the baseline level and did not decrease, indicating that end-expiratory PES does not reflect the clinical condition of patients and may not be a relevant parameter to guide ventilator settings. PEEP changes thus seem to be mainly a result of the use of the empirical PL − Fio2 table for the PES strategy.

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