Effect of positive end-expiratory pressure guided by transpulmonary pressure on oxygenation and respiratory mechanics in acute respiratory distress syndrome patients: a prospective study

The use of positive end-expiratory pressure (PEEP) plays a critical role in managing acute respiratory distress syndrome (ARDS). Various methods for setting PEEP have been proposed, but the efficacy of these strategies is unclear. Our study evaluates the effect of oxygenation and respiratory mechanics on PEEP settings guided by transpulmonary end-expiratory pressure (PL-exp) in ARDS patients. The prospective study included ARDS patients admitted to an Intensive Care Unit (ICU) from November 2021 to October 2023. Patients were ventilated according to the ARDSNet strategy, with PEEP adjustments based on PL-exp using esophageal pressure manometry. Primary outcomes were the partial pressure of arterial oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio and respiratory mechanics at 48 hours. Secondary outcomes included hemodynamic parameters at 48 hours, ventilator days, and ICU length of stay. A total of 46 patients were enrolled, with PEEP settings guided by positive PL-exp. Significant improvements were observed in PaO2/FiO2 ratio (135.8 [Interquartile range (IQR) 100.5–169.8] to 203.6 [IQR 149.0–267.9], p<0.001), respiratory systems of compliance (from 23.8 [IQR 19.7–27.7] mL/cmH2O to 26.7 [IQR 22.2–32.2] mL/cmH2O, p<0.001) at 48 hours post-PEEP adjustment. The mean increase in PEEP was 2 cmH2O, with no significant alterations in hemodynamic parameters and ventilator days. Our findings suggest that esophageal manometry is a minimally invasive tool for setting PEEP-guided PL-exp and shown to improve oxygenation and respiratory mechanics in moderate to severe ARDS patients. These results highlight the need for further targeted research to optimize PEEP settings in ARDS management.