Stanford: LEVITT

No longer use the term ALI. We now categorize by mild/moderate and severe by
categorizing the PF ratios.

Normal lung compliance curve. You and me, when we exhale we reside at FRC..we
are not down to RV. If you have the wind knocked out of you, then you may actually
be at RV. We have surfactant in our airways that keep the lungs from collapsing.

In ARDS the lungs are already weight and due to injury the surfactant is lost.

On the Right is LCC of ARDS

lung inflection point (LIP) where the lung pops open and expands on a
linear compliance curve and then we come to the upper inflection point,
where if you can imagine a full balloon, and each breath that you try to put in
is harder and harder.
Atelectrauma (instead of barotrauma) due to the shear forces across the
alveoli
Holy grail of LPV: attempt to ventilate along this linear portion of the LCC
 o Challenging to measure the lung compliance cure is also difficult

https://www.youtube.com/watch?v=oKH7CtsEgHw

Video of rabbit lung.

As they add PEEP, the lung units are recruited
There has now been 3 large clinical trials comparing high vs. lower PEEP (control
arm is the initial ARDSnet protocol)
P/F ratio
Resp system compliance
slightly higher plateau and mean airway pressures

Standard vent settings in ICU: 100% FiO2 nd 5 of PEEP until ABG back and then 2
hrs later maybe changes are made.

For the high PEEP armyou are already at 10 of PEEP if you are at 50% FiO2

Overall, NET take home: PF ratio is improved (therefore improving oxygenation and
recruiting lung) but also improving resp system compliance but at higher plateau
pressures.

No benefit in mortality/durating of intubation.

* Discordant effects of more PEEP depending on severity of ARDS

But if you have ARDSyou should likely get high PEEP (moderate to severe ARDS)

NEJM article in 2015 looked at the driving pressure (plateau pressure PEEP).
Divide it by TV and you have compliance
Goal Pplat < 30 but if you can imagine being on 10 of PEEP with Pplat of 25 and now
the PEEP 20 and the Pplat is 30but the driving pressure has actually gone
downwhich means that you have improved the compliance.

3. Plateu held constant and increasing PEEP. mortality as driving pressure

increases.
Nice analysis that shows that high pEEP did not have a lower mortality, the only
group with a lower mortality was the groups with a higher driving pressure.

looked at low PEEP arm as the control arm, compared to targeting PEEP at ideal
lung recruitment level (complicated). At what point was the compliance the
bestthen they left PEEP there.
Large trial1010 patietns. Lower mortality in the low PEEP but high driving
pressure arm.

So this does not show same result as previous retrospective analysis

Rate of PTX in high PEEP arm and fairly high rate of patients crashing during
recruitment maneuver. So was the real harm not the higher PEEP but hypoxia or
hypoventilation during airway pressures of 50-55? TBD!

VOLUTRAUMA..the rats that died got a large volume.

WE MUST
Transpulmonary = airway pressure pleural pressure
We do not normally measure pleural pressure. It can be falsely high due to obesity
etc.

In 3rd group, chest wall is more elastic.

Barotrauma in regards to transpulmonary

NEJM in 2009 looking at esophageal balloon as an estimate of pleural pressure.

This is not so idea. Esophagus is not going to = anterior apical segment of the
lung..but at least its an estimate of it. In this trial, they compared it to a low PEEP
arm.
intervention arm: transpulmonary pressure
control: low peep
 Net result: stopped trial early b/c it was targeted toward improved
oxygenation. Stopped trial at 68 patients as they met primary end-point
early.
Post-hoc analysis when adjusting for APACHE II, they got close to seeing a
mortality benefit
o But oxygenation is a terrible end-point!

EPVent 2: MCT titrating PEEP to end-expiratory transpulmonary pressure.

End point: death & ventilator free days

PRONE
* recruit gravity dependent posterior and basilar lung segments
ROSE: early use of neuromuscular blockers