Journal Article

Individualized positive end-expiratory pressure guided by end-expiratory lung volume in early acute respiratory distress syndrome: study protocol for the multicenter, randomized IPERPEEP trial

Mojoli, Francesco, Volta, Carlo Aberto, Bruni, Andrea, Pelosi, Paolo, Foti, Giuseppe, Navalesi, Paolo, Maggiore, Salvatore Maurizio, Grasso, Salvatore, Spinelli, Elena, Bellani, Giacomo, Menga, Luca S., Di Mussi, Rosa, Grieco, Domenico Luca, Pozzi, Marco, Iovino, Carmine Giovanni, Ranieri, V. Marco, Brioni, Matteo, Tonetti, Tommaso, Battaglini, Denise, Spadaro, Savino, Antonelli, Massimo, De Gaetano, Andrea

2022

Overview

Background In acute respiratory distress syndrome (ARDS), response to positive end-expiratory pressure (PEEP) is variable according to different degrees of lung recruitability. The search for a tool to individualize PEEP based on patients’ individual response is warranted. End-expiratory lung volume (EELV) assessment by nitrogen washin-washout aids bedside estimation of PEEP-induced alveolar recruitment and may therefore help titrate PEEP on patient’s individual recruitability. We designed a randomized trial to test whether an individualized PEEP setting protocol driven by EELV measurement may improve a composite clinical outcome in patients with moderate-to-severe ARDS (IPERPEEP trial). Methods IPERPEEP is an open-label, multicenter, randomized trial that will be conducted in 10 intensive care units in Italy and will enroll 132 ARDS patients showing PaO 2 /FiO 2 ratio ≤ 150 mmHg within 24 h from endotracheal intubation while on mechanical ventilation with PEEP 5 cmH 2 O. To standardize lung volumes at study initiation, all patients will undergo mechanical ventilation with tidal volume of 6 ml/kg of predicted body weight and PEEP set to obtain a plateau pressure within 28 and 30 cmH 2 O for 30 min (EXPRESS PEEP). Afterwards, a 5-step decremental PEEP trial will be conducted (EXPRESS PEEP to PEEP 5 cmH 2 O), and EELV will be measured at each step. Recruitment-to-inflation ratio will be calculated for each PEEP range from EELV difference. Patients will be then randomized to receive mechanical ventilation with PEEP set according to the optimal recruitment observed in the PEEP trial (IPERPEEP arm) trial or to achieve a plateau pressure of 28–30 cmH 2 O (control arm, EXPRESS strategy). In both groups, tidal volume size, use of prone positioning and neuromuscular blocking agents, and weaning from PEEP and from mechanical ventilation will be standardized. The primary endpoint of the study is a composite clinical outcome incorporating in-ICU mortality, 60-day ventilator-free days, and serum interleukin-6 concentration over the course of the initial 72 h of treatment. Discussion The IPERPEEP study is a randomized trial powered to elucidate whether an individualized PEEP setting protocol based on bedside assessment of lung recruitability can improve a composite clinical outcome during moderate-to-severe ARDS. Trial registration ClinicalTrials.gov NCT04012073 . Registered 9 July 2019.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Acute respiratory distress syndrome / Artificial respiration / Biomedicine / Care and treatment / Chronic illnesses / Clinical outcomes / Diagnosis / Disease / Enrollments / Esophagus / Health Sciences / Humans / Intensive care / Intubation / Lung / Lung Volume Measurements / Mechanical ventilation / Medicine / Medicine & Public Health / Multicenter Studies as Topic / Neuromuscular diseases / Patients / Positive end-expiratory pressure / Positive-Pressure Respiration / Prognosis / Randomized Controlled Trials as Topic / Respiratory distress syndrome / Respiratory Distress Syndrome - diagnosis / Respiratory Distress Syndrome - therapy / Respiratory system / Statistics for Life Sciences / Study Protocol / Tidal Volume / Transplants & implants / Ventilator-induced lung injury / Ventilators