Monday November 17, 2008
Low tidal volume and PEEP as per ARDS NET trial not good enough?

Study by Daniel Talmor recently published in NEJM addresses this issue. They used esophageal pressure monitoring to guide the changes made on mechanical ventilation.

Method: They randomly assigned patients with acute lung injury or ARDS to undergo mechanical ventilation with PEEP adjusted according to measurements of esophageal pressure (the esophageal-pressure–guided group) or according to the Acute Respiratory Distress Syndrome Network standard-of-care recommendations (the control group).

The primary end point was improvement in oxygenation. The secondary end points included respiratory-system compliance and patient outcomes.

Results: The study was stopped early as it met its termination criteria after enrolling 61 patients. The ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen at 72 hours was 88 mm Hg higher in the esophageal-pressure–guided group than in the control group (95% confidence interval, 78.1 to 98.3; P=0.002). This effect was persistent over the entire follow-up time (at 24, 48, and 72 hours; P=0.001 by repeated-measures analysis of variance).

Respiratory system compliance was also better (p-0.01)

Conclusion: As compared with the standard therapy in ARDS, the management of mechanical ventilation by using esophageal pressure to estimate the transpulmonary pressure significantly improves oxygenation and compliance.



Editorial Comment: Agree with author’s conclusion that further study is needed before it is recommended as guideline.



Reference: Click to get abstract/article

Talmor D, Garge T, Malhotra A, et al. Mechanical Ventilation Guided by esophageal Pressure in Acute Lung Injury. NEJM 2008; 359: 2095-2014