Invasive Mechanical Ventilation Clinical Trial
Official title:
Hemodynamic and Cardiac Effects of Individualized PEEP Titration Using Esophageal Pressure Measurements in ARDS Patients
The acute respiratory distress syndrome (ARDS) is common condition in critical ill patients
affecting 7.2 people / 100,000 population / year and more than 7% of patients with invasive
mechanical ventilation for more than 24 hours. ARDS carries a high hospital mortality of up
to 48% and consumes large amounts of critical care resources. ARDS patients often present
with severe hypoxemia that is refractory to conventional treatment and are thus evaluated
for extracorporeal membrane oxygenation (ECMO). However, uncertainty regarding the
appropriate indication for ECMO and clinical evidence for ECMO as a rescue treatment are
still controversial. In 2012 Grasso and colleagues therefore presented a case series of
influenza A (H1N1) ARDS patients describing the use of esophageal pressure measurements for
individualized PEEP titration to achieve an end expiratory plateau pressure of the lung
(PPLATL) of 25cm H2O. After performing the measurements in 14 patients, ventilator settings
could be adjusted in half of these patients by increasing PEEP which resulted in an increase
of oxygenation measures to an extend that criteria for extracorporeal support where no
longer met and conventional treatment with invasive mechanical ventilation could be
continued. However, uncertainty remains as to whether these results are generalizable to
ARDS of any cause. In addition, increasing PEEP might impact on cardiac function and might
therefore be associated with clinical important hemodynamic effects in these patients.
The investigators aim to evaluate hemodynamic changes in patients with severe ARDS in which
an individualized PEEP treatment strategy can be employed. ARDS will be defined and
stratified according to the Berlin ARDS definition. A naso-gastric probe capable of
measuring esophageal pressure will be inserted directly after admission to the ICU as
previously described. Invasive mechanical ventilation and oesophageal pressure measurements
will be done using the GE Healthcare Carescape R860 ventilator. A pulmonary artery catheters
(Edwards CCOcomb) will be inserted to evaluate the hemodynamic parameters of cardiac output,
pulmonary artery pressures and left atrial pressures. Volumetric parameters will be measured
using tanspulmonary thermodilution devices (Edwards EV1000). Cardiac function will be
addressed in addition by the use of a predefined echocardiography protocol.
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