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ABSTRACT: Background
In face of the Coronavirus Disease (COVID)-19 pandemic, best practice for mechanical ventilation in COVID-19 associated Acute Respiratory Distress Syndrome (ARDS) is intensely debated. Specifically, the rationale for high positive end-expiratory pressure (PEEP) and prone positioning in early COVID-19 ARDS has been questioned.Methods
The first 23 consecutive patients with COVID-19 associated respiratory failure transferred to a single ICU were assessed. Eight were excluded: five were not invasively ventilated and three received veno-venous ECMO support. The remaining 15 were assessed over the first 15 days of mechanical ventilation. Best PEEP was defined by maximal oxygenation and was determined by structured decremental PEEP trials comprising the monitoring of oxygenation, airway pressures and trans-pulmonary pressures. In nine patients the impact of prone positioning on oxygenation was investigated. Additionally, the effects of high PEEP and prone positioning on pulmonary opacities in serial chest x-rays were determined by applying a semiquantitative scoring-system. This investigation is part of the prospective observational PA-COVID-19 study.Findings
Patients responded to initiation of invasive high PEEP ventilation with markedly improved oxygenation, which was accompanied by reduced pulmonary opacities within 6 h of mechanical ventilation. Decremental PEEP trials confirmed the need for high PEEP (17.9 (SD ± 3.9) mbar) for optimal oxygenation, while driving pressures remained low. Prone positioning substantially increased oxygenation (p<0.01).Interpretation
In early COVID-19 ARDS, substantial PEEP values were required for optimizing oxygenation. Pulmonary opacities resolved during mechanical ventilation with high PEEP suggesting recruitment of lung volume.Funding
German Research Foundation, German Federal Ministry of Education and Research.
SUBMITTER: Mittermaier M
PROVIDER: S-EPMC7547915 | biostudies-literature | 2020 Nov
REPOSITORIES: biostudies-literature
Mittermaier Mirja M Pickerodt Philipp P Kurth Florian F de Jarcy Laure Bosquillon LB Uhrig Alexander A Garcia Carmen C Machleidt Felix F Pergantis Panagiotis P Weber Susanne S Li Yaosi Y Breitbart Astrid A Bremer Felix F Knape Philipp P Dewey Marc M Doellinger Felix F Weber-Carstens Steffen S Slutsky Arthur S AS Kuebler Wolfgang M WM Suttorp Norbert N Müller-Redetzky Holger H
EClinicalMedicine 20201011
<h4>Background</h4>In face of the Coronavirus Disease (COVID)-19 pandemic, best practice for mechanical ventilation in COVID-19 associated Acute Respiratory Distress Syndrome (ARDS) is intensely debated. Specifically, the rationale for high positive end-expiratory pressure (PEEP) and prone positioning in early COVID-19 ARDS has been questioned.<h4>Methods</h4>The first 23 consecutive patients with COVID-19 associated respiratory failure transferred to a single ICU were assessed. Eight were exclu ...[more]